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Sample records for prolonged mechanical ventilation

  1. Variation in Definition of Prolonged Mechanical Ventilation.

    PubMed

    Rose, Louise; McGinlay, Michael; Amin, Reshma; Burns, Karen Ea; Connolly, Bronwen; Hart, Nicholas; Jouvet, Philippe; Katz, Sherri; Leasa, David; Mawdsley, Cathy; McAuley, Danny F; Schultz, Marcus J; Blackwood, Bronagh

    2017-10-01

    Consistency of definitional criteria for terminology applied to describe subject cohorts receiving mechanical ventilation within ICU and post-acute care settings is important for understanding prevalence, risk stratification, effectiveness of interventions, and projections for resource allocation. Our objective was to quantify the application and definition of terms for prolonged mechanical ventilation. We conducted a scoping review of studies (all designs except single-case study) reporting a study population (adult and pediatric) using the term prolonged mechanical ventilation or a synonym. We screened 5,331 references, reviewed 539 full-text references, and excluded 120. Of the 419 studies (representing 38 countries) meeting inclusion criteria, 297 (71%) reported data on a heterogeneous subject cohort, and 66 (16%) included surgical subjects only (46 of those 66, 70% cardiac surgery). Other studies described COPD (16, 4%), trauma (22, 5%), neuromuscular (17, 4%), and sepsis (1, 0.2%) cohorts. A total of 741 terms were used to refer to the 419 study cohorts. The most common terms were: prolonged mechanical ventilation (253, 60%), admission to specialized unit (107, 26%), and long-term mechanical ventilation (79, 19%). Some authors (282, 67%) defined their cohorts based on duration of mechanical ventilation, with 154 studies (55%) using this as the sole criterion. We identified 37 different durations of ventilation ranging from 5 h to 1 y, with > 21 d being the most common (28 of 282, 7%). For studies describing a surgical cohort, minimum ventilation duration required for inclusion was ≥ 24 h for 20 of 66 studies (30%). More than half of all studies (237, 57%) did not provide a reason/rationale for definitional criteria used, with only 28 studies (7%) referring to a consensus definition. We conclude that substantial variation exists in the terminology and definitional criteria for cohorts of subjects receiving prolonged mechanical ventilation. Standardization of

  2. Bilateral Scapulohumeral Ankylosis after Prolonged Mechanical Ventilation

    PubMed Central

    Schreinemakers, J. Rieneke; van Noort, Arthur; Rademakers, Maarten V.

    2016-01-01

    This case demonstrates a rarely reported bilateral scapulohumeral bony ankylosis. A young woman developed extensive heterotopic ossifications (HOs) in both shoulder joints after being mechanically ventilated for several months at the intensive care unit in a comatose status. She presented with a severe movement restriction of both shoulder joints. Surgical resection of the bony bridges was performed in 2 separate sessions with a significant improvement of shoulder function afterwards. No postoperative complications, pain, or recurrence of HOs were noted at 1-year follow-up. Mechanical ventilation, immobilization, neuromuscular blockage, and prolonged sedation are known risk factors for the development of HOs in the shoulder joints. Relatively early surgical resection of the HOs can be performed safely in contrary to earlier belief. Afterwards, nonsteroidal anti-inflammatory drugs and/or radiation therapy can be possible treatment modalities to prevent recurrence of HOs. PMID:27583120

  3. Prolonged propofol infusion for mechanically ventilated children.

    PubMed

    Sasabuchi, Y; Yasunaga, H; Matsui, H; Lefor, A K; Fushimi, K

    2016-04-01

    We retrospectively analysed 30-day mortality and duration of intubation for 8016 children ventilated for three or more days, sedated with midazolam (n = 7716) or propofol (n = 300). We matched the propensity scores of 263 pairs of children. The propensity-matched 30-day mortality (95% CI) was similar: 17/263 (6.5%) with midazolam vs. 24/263 (9.1%) with propofol, p = 0.26. Weaning from mechanical ventilation of children sedated with midazolam was slower than weaning of children sedated with propofol, subhazard ratio (95% CI) 1.43 (1.18-1.73), p < 0.001. © 2016 The Association of Anaesthetists of Great Britain and Ireland.

  4. Pediatric Prolonged Mechanical Ventilation: Considerations for Definitional Criteria.

    PubMed

    Sauthier, Michaël; Rose, Louise; Jouvet, Philippe

    2017-01-01

    A 2005 consensus conference led by the National Association for Medical Direction of Respiratory Care (NAMDRC) defined prolonged mechanical ventilation (PMV) for adults as invasive and/or noninvasive mechanical ventilation (NIV) for ≥ 21 consecutive days for ≥ 6 h/d. In children, no such consensus definition exists. This results in substantial variability in definitional criteria, making study of the impact and outcomes of PMV across and within settings problematic. The objective of this work was to identify how PMV for children and neonates is described in the literature and to outline pediatric/neonatal considerations related to PMV, with the goal of proposing a pediatric/neonatal adaptation to the NAMDRC definition. We searched electronic databases for studies describing PMV in children. We extracted definitional criteria and developed recommendations based on the literature review and our clinical experience. Of the 416 citations obtained, 87 met inclusion criteria, totaling 34,255 subjects. Identified criteria for the pediatric PMV definition included: number of consecutive days of mechanical ventilation (ranging from 6 h to 3 months), inclusion of NIV, time spent off the ventilator during weaning (considered as same ventilation episode), and importance of chronological age (term neonates) and postmenstrual age for preterm neonates. We considered high-flow nasal cannula; however, we determined that its current role as a weaning adjunct is unclear. Therefore, we developed the following recommendations for the pediatric PMV definition: ≥ 21 consecutive days (after 37 weeks postmenstrual age) of ventilation for ≥ 6 h/d considering invasive ventilation and NIV and including short interruptions (< 48 h) of ventilation during the weaning process as the same episode of ventilation. We propose a definition of pediatric PMV that incorporates the number of consecutive days of mechanical ventilation while taking into account use of NIV and lung maturity and

  5. Depressive Disorders during Weaning from Prolonged Mechanical Ventilation

    PubMed Central

    Jubran, Amal; Lawm, Gerald; Kelly, Joanne; Duffner, Lisa A.; Gungor, Gokay; Collins, Eileen G.; Lanuza, Dorothy M.; Hoffman, Leslie A.; Tobin, Martin J.

    2010-01-01

    Purpose Patients who require mechanical ventilation are at risk of emotional stress because of total dependence on a machine for breathing. The stress may negatively impact ventilator weaning and survival. The purpose of this study was to determine whether depressive disorders in patients being weaned from prolonged mechanical ventilation are linked to weaning failure and decreased survival. Methods A prospective study of 478 consecutive patients transferred to a long-term acute care hospital for weaning from prolonged ventilation was undertaken. A clinical psychologist conducted a psychiatric interview to assess for the presence of depressive disorders. Results Of the 478 patients, 142 had persistent coma or delirium and were unable to be evaluated for depressive disorders. Of the remaining 336 patients, 142 (42%) were diagnosed with depressive disorders. In multivariate analysis, co-morbidity score (odds ratio [OR], 1.23, p=0.007), functional dependence before the acute illness (OR, 1.70, p=0.03), and history of psychiatric disorders (OR, 3.04, p=0.0001) were independent predictors of depressive disorders. The rate of weaning failure was higher in patients with depressive disorders than in those without such disorders (61% versus 33%, p=0.0001), as was mortality (24% versus 10%, p=0.0008). The presence of depressive disorders was independently associated with mortality (OR, 4.3; p=0.0002); age (OR, 1.06; p=0.001) and co-morbidity score (OR, 1.24; p=0.02) also predicted mortality. Conclusion Depressive disorders were diagnosed in 42% of patients who are being weaned from prolonged ventilation. Patients with depressive disorders were more likely to experience weaning failure and death. PMID:20232042

  6. The Impact of Ventilator-Associated Events in Critically Ill Subjects With Prolonged Mechanical Ventilation.

    PubMed

    Kobayashi, Hidetsugu; Uchino, Shigehiko; Takinami, Masanori; Uezono, Shoichi

    2017-07-18

    The Centers for Disease Control and Prevention recently released a surveillance definition for respiratory complications in ventilated patients, ventilator-associated events (VAE), to replace ventilator-associated pneumonia (VAP). VAE consists of ventilator-associated conditions (VAC), infection-related ventilator-associated complications (IVAC), and possible VAP. A duration of mechanical ventilation of at least 4 d is required to diagnose VAE. However, the observed duration of mechanical ventilation was < 4 d in many previous studies. We evaluated the impact of VAE on clinical outcomes in critically ill subjects who required mechanical ventilation for ≥ 4 d. This single-center retrospective cohort study was conducted in the general ICU of an academic hospital. We included 407 adult subjects who were admitted to the ICU and required mechanical ventilation for at least 4 d. VAC and IVAC were identified from the electronic medical records. VAP was defined according to the Centers for Disease Control and Prevention 2008 criteria and was identified from the surveillance data of the infection control team of our hospital. Clinical outcomes were studied in the VAC, IVAC, and VAP groups. Possible VAP was not investigated. Higher mortality was seen in VAC and IVAC subjects, but not in VAP subjects, compared with those without VAEs and VAP. By multivariable hazard analysis for hospital mortality, IVAC was independently associated with hospital mortality (hazard ratio 2.42, 95% CI 1.39-4.20, P = .002). VAC also tended to show a similar association with hospital mortality (hazard ratio 1.45, 95% CI 0.97-2.18, P = .07). On the other hand, VAP did not increase a hazard of hospital death (hazard ratio 1.08, 95% CI 0.44-2.66, P = .87). We found that VAE was related to hospital mortality in critically ill subjects with prolonged mechanical ventilation, and that VAP was not. Copyright © 2017 by Daedalus Enterprises.

  7. Predictors of Prolonged Mechanical Ventilation after Open Heart Surgery

    PubMed Central

    Totonchi, Ziae; Baazm, Farah; Chitsazan, Mitra; Seifi, Somayeh; Chitsazan, Mandana

    2014-01-01

    Introduction: Due to the importance of prolonged mechanical ventilation (PMV) as a postoperative complication, predicting "high-risk" patients by identifying predisposing risk factors is of important issue. The present study was aimed to identify perioperative variables associated with PMV in patients undergoing open heart surgery. Methods: A total of 743 consecutive patients, American Society of Anesthesiologists (ASA) physical status class III, who were scheduled to undergo open heart surgery using cardiopulmonary bypass were included in this observational study. Perioperative variables were compared between the patients with and without PMV, as defined by an extubation time of >48 h. Results: PMV occurred in 45 (6.1%) patients. On univariate analysis, pre-operative variables; including gender, history of chronic obstructive pulmonary disease (COPD); chronic kidney disease and endocarditis, intra-operative variables; including type of surgery, operation time, pump time, transfusion in operating room and postoperative variables; including bleeding and inotrope-dependency were significantly different between patients with and without PMV (all P<0.001, except for COPD and transfusion in operating room; P=0.004 and P=0.017, respectively). Conclusion: Our findings reinforce that risk stratification for predicting delayed extubation should be an important aspect of preoperative clinical evaluation in all anesthesiology settings. PMID:25610551

  8. Prolonged mechanical ventilation after CABG: risk factor analysis.

    PubMed

    Gumus, Funda; Polat, Adil; Yektas, Abdulkadir; Totoz, Tolga; Bagci, Murat; Erentug, Vedat; Alagol, Aysin

    2015-02-01

    Prolonged ventilation (PV) after coronary artery bypass graft (CABG) surgery is a common postoperative complication. Preoperative and operative parameters were evaluated in order to identify the patients at risk for prolonged ventilation postoperatively in coronary artery bypass graft (CABG) patients. Retrospective. Research and training hospital, single institution. The authors analyzed the prospectively collected data of 830 on- and off-pump coronary bypass patients. The relationships of PV (>24 hours) with preoperative and operative parameters were evaluated with logistic regression analysis. Forty-six patients (5.6%) required PV postoperatively. Hospital mortality was significantly higher in this group (45.7% v 4.0%; p = 0.0001). Univariate analysis showed that these patients were older (65.6±9.3 v 60.4±9.9; p = 0.001), had higher incidences of cerebrovascular disease (21.7% v 10.5%; p = 0.032), advanced ASA (58.7% v 41.8%; p = 0.026) and NYHA classes (32.6% v 12.2%; p = 0.001), and chronic renal dysfunction (20.0% v 4.0%; p = 0.0001). Concomitant procedures were more commonly performed in these patients (30.4% v 7.8%; p = 0.0001), and total durations of perfusion were longer (147.2±69.1 v 95.7±33.9 minutes; p = 0.0001). In regression analysis, advanced NYHA class (odds ratio = 8.2; 95% CI = 1.5-43.5; p = 0.015), chronic renal dysfunction (odds ratio = 7.7; 95% CI = 1.3-47.6; p = 0.027), and longer perfusion durations (p = 0.012) were found to be independently associated with delayed weaning from the ventilator. Every 1-minute increase over 82.5 minutes of cardiopulmonary bypass increased risk of delayed extubation by 3.5% (95% CI = 0.8%-6.4%). Postoperative prolonged ventilation is associated with advanced NYHA class, chronic renal dysfunction and longer perfusion times in CABG patients. Copyright © 2014 Elsevier Inc. All rights reserved.

  9. Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery.

    PubMed

    Nabozny, Michael J; Barnato, Amber E; Rathouz, Paul J; Havlena, Jeffrey A; Kind, Amy J; Ehlenbach, William J; Zhao, Qianqian; Ronk, Katie; Smith, Maureen A; Greenberg, Caprice C; Schwarze, Margaret L

    2016-06-01

    Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation. Retrospective cohort study. Hospitals throughout the United States. Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009. None. We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized. Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk

  10. FAMILY PRESENCE AND SURVEILLANCE DURING WEANING FROM PROLONGED MECHANICAL VENTILATION

    PubMed Central

    Happ, Mary Beth; Swigart, Valerie A.; Tate, Judith A.; Arnold, Robert A.; Sereika, Susan M.; Hoffman, Leslie A.

    2007-01-01

    Objectives The research was designed to describe the care and communication processes during weaning from long-term mechanical ventilation (LTMV). A portion of those findings, specifically, how family members interact with the patient and respond to the ventilator and associated ICU bedside equipment during LTMV weaning, are reported here. Methods Ethnography conducted in a medical intensive care unit (MICU) and step-down MICU following 30 adults who were weaning from LTMV (> 4 days). Data collection involved field observations conducted from November 2001 to July 2003, interviews with patients, family members, and MICU clinicians, and clinical record review. Results Family members were present at the LTMV patients’ bedside during 46% of weaning trials and interacted with patients through touch, talking, and surveillance. Families’ bedside surveillance activities were interpretive of numerical monitor displays and laboratory values, protective of patient safety and comfort, and often focused exclusively on weaning. Interpretive language and surveillance were learned from and imitative of clinician behaviors. Clinicians characterized the family’s presence as helpful, a hindrance, or having no effect on the weaning process. Quantitative analysis using random coefficient modeling examining the effect of family presence on length of weaning trials showed significantly longer daily weaning trials when families were present (p < .0001). Conclusion Critical care clinicians influence families’ acquisition of interpretive surveillance skills at the bedside of patients who are weaning from LTMV. This study provides a potentially useful conceptual framework of family behaviors with long-term critically ill patients that could enhance the dialogue about family-centered care and guide future research on family presence in the ICU. PMID:17234477

  11. The growing role of noninvasive ventilation in patients requiring prolonged mechanical ventilation.

    PubMed

    Hess, Dean R

    2012-06-01

    For many patients with chronic respiratory failure requiring ventilator support, noninvasive ventilation (NIV) is preferable to invasive support by tracheostomy. Currently available evidence does not support the use of nocturnal NIV in unselected patients with stable COPD. Several European studies have reported benefit for high intensity NIV, in which setting of inspiratory pressure and respiratory rate are selected to achieve normocapnia. There have also been studies reporting benefit for the use of NIV as an adjunct to exercise training. NIV may be useful as an adjunct to airway clearance techniques in patients with cystic fibrosis. Accumulating evidence supports the use of NIV in patients with obesity hypoventilation syndrome. There is considerable observational evidence supporting the use of NIV in patients with chronic respiratory failure related to neuromuscular disease, and one randomized controlled trial reported that the use of NIV was life-prolonging in patients with amyotrophic lateral sclerosis. A variety of interfaces can be used to provide NIV in patients with stable chronic respiratory failure. The mouthpiece is an interface that is unique in this patient population, and has been used with success in patients with neuromuscular disease. Bi-level pressure ventilators are commonly used for NIV, although there are now a new generation of intermediate ventilators that are portable, have a long battery life, and can be used for NIV and invasive applications. Pressure support ventilation, pressure controlled ventilation, and volume controlled ventilation have been used successfully for chronic applications of NIV. New modes have recently become available, but their benefits await evidence to support their widespread use. The success of NIV in a given patient population depends on selection of an appropriate patient, selection of an appropriate interface, selection of an appropriate ventilator and ventilator settings, the skills of the clinician, the

  12. Early Fluid Overload Prolongs Mechanical Ventilation in Children With Viral-Lower Respiratory Tract Disease.

    PubMed

    Ingelse, Sarah A; Wiegers, Hanke M G; Calis, Job C; van Woensel, Job B; Bem, Reinout A

    2017-03-01

    Viral-lower respiratory tract disease is common in young children worldwide and is associated with high morbidity. Acute respiratory failure due to viral-lower respiratory tract disease necessitates PICU admission for mechanical ventilation. In critically ill patients in PICU settings, early fluid overload is common and associated with adverse outcomes such as prolonged mechanical ventilation and increased mortality. It is unclear, however, if this also applies to young children with viral-lower respiratory tract disease induced acute respiratory failure. In this study, we aimed to investigate the relation of early fluid overload with adverse outcomes in mechanically ventilated children with viral-lower respiratory tract disease in a retrospective dataset. Retrospective cohort study. Single, tertiary referral PICU. One hundred thirty-five children (< 2 yr old) with viral-lower respiratory tract disease requiring mechanical ventilation admitted to the PICU of the Academic Medical Center, Amsterdam between 2008 and 2014. None. The cumulative fluid balance on day 3 of mechanical ventilation was compared against duration of mechanical ventilation (primary outcome) and daily mean oxygen saturation index (secondary outcome), using uni- and multivariable linear regression. In 132 children, the mean cumulative fluid balance on day 3 was + 97.9 (49.2) mL/kg. Higher cumulative fluid balance on day 3 was associated with a longer duration of mechanical ventilation in multivariable linear regression (β = 0.166; p = 0.048). No association was found between the fluid status and oxygen saturation index during the period of mechanical ventilation. Early fluid overload is an independent predictor of prolonged mechanical ventilation in young children with viral-lower respiratory tract disease. This study suggests that avoiding early fluid overload is a potential target to reduce duration of mechanical ventilation in these children. Prospective testing in a clinical trial is

  13. Long-Term Outcomes and Health Care Utilization after Prolonged Mechanical Ventilation.

    PubMed

    Hill, Andrea D; Fowler, Robert A; Burns, Karen E A; Rose, Louise; Pinto, Ruxandra L; Scales, Damon C

    2017-03-01

    Limited data are available to characterize the long-term outcomes and associated costs for patients who require prolonged mechanical ventilation (PMV; defined here as mechanical ventilation for longer than 21 d). To examine the association between PMV and mortality, health care utilization, and costs after critical illness. Population-based cohort study of adults who received mechanical ventilation in an intensive care unit (ICU) in Ontario, Canada between 2002 and 2013. We used linked administrative databases to determine discharge disposition, and ascertain 1-year mortality (primary outcome), readmissions to hospital and ICU, and health care costs for hospital survivors. Overall, 11,594 (5.4%) patients underwent PMV, with 42.4% of patients dying in the hospital (vs. 27.6% of patients who did not undergo prolonged ventilation; P < 0.0001). Patients on prolonged ventilation were more frequently discharged to other facilities or home with health care support (84.8 vs. 43.5%, P < 0.0001). Among hospital survivors, estimated mortality was higher for patients who underwent PMV: 16.6 versus 11% at 1 year and 42.0 versus 30.4% at 5 years. At 1 year after hospital discharge, patients on prolonged ventilation had higher rates of hospital readmission (47.2 vs. 37.7%; adjusted odds ratio = 1.20; 95% confidence interval = 1.14-1.26), ICU readmission (19.0 vs. 11.6%; adjusted odds ratio = 1.49; 95% confidence interval: 1.39, 1.60), and total health care costs: median (interquartile range) Can $32,526 ($20,821-$56,102) versus Can $13,657 ($5,946-$38,022). Increasing duration of mechanical ventilation was associated with higher mortality and health care utilization. Critically ill patients who undergo mechanical ventilation in an ICU for longer than 21 days have high in-hospital mortality and greater postdischarge mortality, health care utilization, and health care costs compared with patients who undergo mechanical ventilation for a shorter period of time.

  14. Parameters affecting the tidal volume during expiratory abdominal compression in patients with prolonged tracheostomy mechanical ventilation

    PubMed Central

    Morino, Akira; Shida, Masahiro; Tanaka, Masashi; Sato, Kimihiro; Seko, Toshiaki; Ito, Shunsuke; Ogawa, Shunichi; Takahashi, Naoaki

    2015-01-01

    [Purpose] The aim of this study was to clarify physical parameters affecting the tidal volume during expiratory abdominal compression in patients with prolonged tracheostomy mechanical ventilation. [Methods] Eighteen patients with prolonged mechanical ventilation were included in this study. Expiratory abdominal compression was performed on patients lying in a supine position. The abdomen above the navel was vertically compressed in synchronization with expiration and released with inspiration. We measured the tidal volume during expiratory abdominal compression. [Results] The mean tidal volume during expiratory abdominal compression was higher than that at rest (430.6 ± 127.1 mL vs. 344.0 ± 94.3 mL). The tidal volume during expiratory abdominal compression was correlated with weight, days of ventilator support, dynamic compliance and abdominal expansion. Stepwise multiple regression analysis revealed that weight (β = 0.499), dynamic compliance (β = 0.387), and abdominal expansion (β = 0.365) were factors contributing to the tidal volume during expiratory abdominal compression. [Conclusion] Expiratory abdominal compression increased the tidal volume in patients with prolonged tracheostomy mechanical ventilation. The tidal volume during expiratory abdominal compression was influenced by each of the pulmonary conditions and the physical characteristics. PMID:26311947

  15. Indicators of fatigue and of prolonged weaning from mechanical ventilation in surgical patients.

    PubMed

    O'Keefe, G E; Hawkins, K; Boynton, J; Burns, D

    2001-01-01

    Indicators of weaning success have been tested primarily in patients who have been ventilated for short periods of time, and they may not be as accurate in cases where support has been required for longer than a few days. In patients requiring longer periods of support it is difficult to estimate the likelihood of successful liberation. Therefore we evaluated established weaning indices for their accuracy in surgical patients who required > or = 72 hours of mechanical ventilation. Surgical patients who required mechanical ventilation for > or = 72 hours were prospectively followed (over 6 months). We obtained standard indices of ventilatory function daily once patients were ready to wean. These indices included the respiratory rate/tidal volume ratio (RSBI), the maximal inspiratory pressure, and the minute ventilation. The duration of weaning and explicitly defined episodes of fatigue were the outcomes of interest. Statistical analyses evaluated the multiple factors that might influence the duration of weaning. Ninety-five patients (66% trauma; 34% surgery) survived to begin weaning, and 93% were liberated. The median duration of mechanical ventilation prior to weaning was 4 days (range 3-16 days), and the median duration of weaning was 3 days (range 0-56 days). Fatigue occurred in 36 patients and was not reliably predicted by any of the weaning measurements. However, a RSBI of > 105 on the first day of weaning was associated with prolonged weaning. By multivariate analysis, an RSBI of > 105 on the first day of weaning predicted prolonged weaning (hazard ratio 1.9; p = 0.03). After 72 hours of mechanical ventilation, clinical fatigue and successful liberation are not reliably predicted by standard indices of respiratory muscle strength and reserve. However, an RSBI of >105 observed once the patient is ready to wean is associated with prolonged weaning.

  16. Prolonged mechanical ventilation in Canadian intensive care units: a national survey.

    PubMed

    Rose, Louise; Fowler, Robert A; Fan, Eddy; Fraser, Ian; Leasa, David; Mawdsley, Cathy; Pedersen, Cheryl; Rubenfeld, Gordon

    2015-02-01

    We sought to describe prevalence and care practices for patients experiencing prolonged mechanical ventilation (PMV), defined as ventilation for 21 or more consecutive days and medical stability. We provided the survey to eligible units via secure Web link to a nominated unit champion from April to November 2012. Weekly telephone and e-mail reminders were sent for 6 weeks. Response rate was 215 (90%) of 238 units identifying 308 patients requiring PMV on the survey day occupying 11% of all Canadian ventilator-capable beds. Most units (81%) used individualized plans for both weaning and mobilization. Weaning and mobilization protocols were available in 48% and 38% of units, respectively. Of those units with protocols, only 25% reported weaning guidance specific to PMV, and 11% reported mobilization content for PMV. Only 30% of units used specialized mobility equipment. Most units referred to speech language pathologists (88%); use of communication technology was infrequent (11%). Only 29% routinely referred to psychiatry/psychology, and 17% had formal discharge follow-up services. Prolonged mechanical ventilation patients occupied 11% of Canadian acute care ventilator bed capacity. Most units preferred an individualized approach to weaning and mobilization with considerable variation in weaning methods, protocol availability, access to specialized rehabilitation equipment, communication technology, psychiatry, and discharge follow-up. Copyright © 2014 Elsevier Inc. All rights reserved.

  17. Early Rehabilitation Therapy Is Beneficial for Patients With Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery.

    PubMed

    Dong, Zehua; Yu, Bangxu; Zhang, Quanfang; Pei, Haitao; Xing, Jinyan; Fang, Wei; Sun, Yunbo; Song, Zhen

    2016-01-01

    We investigated the effects of early rehabilitation therapy on prolonged mechanically ventilated patients after coronary artery bypass surgery (CABG).A total of 106 patients who underwent CABG between June 2012 and May 2015 were enrolled and randomly assigned into an early rehabilitation group (53 cases) and a control group (53 cases). The rehabilitation therapy consisted of 6 steps including head up, transferring from supination to sitting, sitting on the edge of bed, sitting in a chair, transferring from sitting to standing, and walking along a bed. The patients received rehabilitation therapy in the intensive care unit (ICU) after CABG in the early rehabilitation group. The control group patients received rehabilitation therapy after leaving the ICU.The results showed that the early rehabilitation therapy could significantly decrease the duration of mechanical ventilation (early rehabilitation group: 8.1 ± 3.3 days; control group: 13.9 ± 4.1 days, P < 0.01), hospital stay (early rehabilitation group: 22.0 ± 3.8 days; control group: 29.1 ± 4.6 days, P < 0.01), and ICU stay (early rehabilitation group: 11.7 ± 3.2 days; control group: 18.3 ± 4.2 days, P < 0.01) for patients requiring more than 72 hours prolonged mechanical ventilation. The results of Kaplan-Meier analysis showed that the proportions of patients remaining on mechanical ventilation in the early rehabilitation group were larger than that in the control group after 7 days of rehabilitation therapy (logrank test: P < 0.01). The results provide evidence for supporting the application of early rehabilitation therapy in patients requiring prolonged mechanical ventilation after CABG.

  18. Higher Pulmonary Dead Space May Predict Prolonged Mechanical Ventilation After Cardiac Surgery

    PubMed Central

    Ong, Thida; Stuart-Killion, Regan B.; Daniel, Brian M.; Presnell, Laura B.; Zhuo, Hanjing; Matthay, Michael A.; Liu, Kathleen D.

    2009-01-01

    Summary Children undergoing congenital heart surgery are at risk for prolonged mechanical ventilation and length of hospital stay. We investigated the prognostic value of pulmonary dead space fraction as a non-invasive, physiologic marker in this population. In a prospective, cross-sectional study, we measured pulmonary dead space fraction in 52 intubated, pediatric patients within 24 hr postoperative from congenital heart surgery. Measurements were obtained with a bedside, non-invasive cardiac output (NICO) monitor (Respironics Novametrix, Inc., Wallingford, CT). Median pulmonary dead space fraction was 0.46 (25–75% IQR 0.34–0.55). Pulmonary dead space fraction significantly correlated with duration of mechanical ventilation and length of hospital stay in the entire cohort (rs=0.51, P=0.0002; rs=0.51, P=0.0002) and in the subset of patients without residual intracardiac shunting (rs=0.45, P=0.008; rs=0.49, P=0.004). In a multivariable logistic regression model, pulmonary dead space fraction remained an independent predictor for prolonged mechanical ventilation in the presence of cardiopulmonary bypass time and ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (OR 2.2; 95% CI 1.14–4.38; P=0.02). The area under the receiver operator characteristic curve for this model was 0.91. Elevated pulmonary dead space fraction is associated with prolonged mechanical ventilation and hospital stay in pediatric patients who undergo surgery for congenital heart disease and has additive predictive value in identifying those at risk for longer duration of mechanical ventilation. Pulmonary dead space may be a useful prognostic tool for clinicians in patients who undergo congenital heart surgery. PMID:19382217

  19. Gorham syndrome with postoperative respiratory failure and requiring prolonged mechanical ventilation.

    PubMed

    Huang, Shiang-Yu; Lee, Ying-Min; Tzeng, Shiau-Tzu; Su, Chiu-Ping; Huang, Shiu-Feng; Wu, Yao-Kuang; Lan, Chou-Chin

    2013-11-01

    Gorham syndrome is a rare disease that presents as progressive osteolysis, and may affect any part of the skeleton. The pathologic process involves the replacement of normal bone by aggressively expanding but non-neoplastic vascular tissue, resulting in massive osteolysis of the adjacent bone. If the spine and ribs are affected, the subsequent kyphosis and chest wall deformity may cause severe restrictive ventilatory impairment. We report a 34-year-old male with Gorham syndrome presenting as progressive kyphosis, severe back pain, unstable gait, and exertional dyspnea. Pulmonary function testing revealed severe restrictive ventilatory impairment. He underwent spinal surgery but could not be extubated after surgery. Postoperative left lower lung pneumonia and respiratory failure required prolonged mechanical ventilation. After a weaning program of pressure support ventilation and T-piece spontaneous breathing trials, he was successfully weaned from mechanical ventilation.

  20. A Prognostic Model for One-year Mortality in Patients Requiring Prolonged Mechanical Ventilation

    PubMed Central

    Carson, Shannon S.; Garrett, Joanne; Hanson, Laura C.; Lanier, Joyce; Govert, Joe; Brake, Mary C.; Landucci, Dante L.; Cox, Christopher E.; Carey, Timothy S.

    2009-01-01

    Objective A measure that identifies patients who are at high risk of mortality after prolonged ventilation will help physicians communicate prognosis to patients or surrogate decision-makers. Our objective was to develop and validate a prognostic model for 1-year mortality in patients ventilated for 21 days or more. Design Prospective cohort study. Setting University-based tertiary care hospital Patients 300 consecutive medical, surgical, and trauma patients requiring mechanical ventilation for at least 21 days were prospectively enrolled. Measurements and Main Results Predictive variables were measured on day 21 of ventilation for the first 200 patients and entered into logistic regression models with 1-year and 3-month mortality as outcomes. Final models were validated using data from 100 subsequent patients. One-year mortality was 51% in the development set and 58% in the validation set. Independent predictors of mortality included requirement for vasopressors, hemodialysis, platelet count ≤150 ×109/L, and age ≥50. Areas under the ROC curve for the development model and validation model were 0.82 (se 0.03) and 0.82 (se 0.05) respectively. The model had sensitivity of 0.42 (se 0.12) and specificity of 0.99 (se 0.01) for identifying patients who had ≥90% risk of death at 1 year. Observed mortality was highly consistent with both 3- and 12-month predicted mortality. These four predictive variables can be used in a simple prognostic score that clearly identifies low risk patients (no risk factors, 15% mortality) and high risk patients (3 or 4 risk factors, 97% mortality). Conclusions Simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged ventilation. PMID:18552692

  1. Risk factors for prolonged mechanical ventilation after total aortic arch replacement for acute DeBakey type I aortic dissection.

    PubMed

    Li, Cheng-Nan; Chen, Lei; Ge, Yi-Peng; Zhu, Jun-Ming; Liu, Yong-Min; Zheng, Jun; Liu, Wei; Ma, Wei-Guo; Sun, Li-Zhong

    2014-09-01

    EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation. Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation. The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p<0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p<0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 10⁹/L (p<0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75). EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation. Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic

  2. Long-Term Acute Care Patients Weaning From Prolonged Mechanical Ventilation Maintain Circadian Rhythm

    PubMed Central

    Koldobskiy, Dafna; Diaz-Abad, Montserrat; Scharf, Steven M; Brown, John; Verceles, Avelino C

    2015-01-01

    BACKGROUND Circadian rhythm regulates many physiologic and immunologic processes. Disruption of these processes has been demonstrated in acutely ill, mechanically ventilated patients in the ICU setting. Light has not been studied as an entraining stimulus in the chronically mechanically ventilated patient. The purpose of this study was to determine the association of naturally occurring ambient light levels in a long-term acute care (LTAC) hospital with circadian rhythm in patients recovering from critical illness and requiring prolonged mechanical ventilation (PMV). METHODS We performed a prospective observational study of 15 adult patients who were recovering from critical illness and receiving PMV and who were admitted to the ventilator weaning unit at an LTAC hospital. Demographic data were obtained from chart review. Light stimuli in each patient room were assessed using a photometer device placed at eye level. Circadian rhythm was assessed by wrist actigraphy. Cumulative data were obtained from each device for a 48-h period, averaged into 4-h intervals, and analyzed. RESULTS Patients receiving PMV were obese (mean body mass index of 32.7 ± 10.3 kg/m2) and predominantly female (73%) and had an average age of 63.1 ± 14.3 y. Light exposure to this cohort maintained diurnal variation (P < .001) and was significantly different across time periods. Circadian rhythm, as represented by actigraphy, also maintained diurnal variation (P < .001) and was in phase with light. Linear regression of movement and time demonstrated a moderate relationship between light and actigraphy (R2 = 0.56). CONCLUSIONS Despite requiring continued high-level care and a prolonged stay in a medical facility, patients recovering from critical illness and actively weaning from PMV maintain their circadian rhythm in phase with normal diurnal variations of light. PMID:24026184

  3. Long-term acute care patients weaning from prolonged mechanical ventilation maintain circadian rhythm.

    PubMed

    Koldobskiy, Dafna; Diaz-Abad, Montserrat; Scharf, Steven M; Brown, John; Verceles, Avelino C

    2014-04-01

    Circadian rhythm regulates many physiologic and immunologic processes. Disruption of these processes has been demonstrated in acutely ill, mechanically ventilated patients in the ICU setting. Light has not been studied as an entraining stimulus in the chronically mechanically ventilated patient. The purpose of this study was to determine the association of naturally occurring ambient light levels in a long-term acute care (LTAC) hospital with circadian rhythm in patients recovering from critical illness and requiring prolonged mechanical ventilation (PMV). We performed a prospective observational study of 15 adult patients who were recovering from critical illness and receiving PMV and who were admitted to the ventilator weaning unit at an LTAC hospital. Demographic data were obtained from chart review. Light stimuli in each patient room were assessed using a photometer device placed at eye level. Circadian rhythm was assessed by wrist actigraphy. Cumulative data were obtained from each device for a 48-h period, averaged into 4-h intervals, and analyzed. Patients receiving PMV were obese (mean body mass index of 32.7 ± 10.3 kg/m2) and predominantly female (73%) and had an average age of 63.1 ± 14.3 y. Light exposure to this cohort maintained diurnal variation (P < .001) and was significantly different across time periods. Circadian rhythm, as represented by actigraphy, also maintained diurnal variation (P < .001) and was in phase with light. Linear regression of movement and time demonstrated a moderate relationship between light and actigraphy (R2 = 0.56). Despite requiring continued high-level care and a prolonged stay in a medical facility, patients recovering from critical illness and actively weaning from PMV maintain their circadian rhythm in phase with normal diurnal variations of light.

  4. Apocynin attenuates diaphragm oxidative stress and protease activation during prolonged mechanical ventilation

    PubMed Central

    McClung, Joseph M.; Van Gammeren, Darin; Whidden, Melissa A.; Falk, Darin J.; Kavazis, Andreas N.; Hudson, Matt B.; Gayan-Ramirez, Ghislaine; Decramer, Marc; DeRuisseau, Keith C.; Powers, Scott K.

    2010-01-01

    Objective To investigate whether apocynin protects the diaphragm from wasting and oxidative stress during mechanical ventilation (MV). Design Prospective, randomized, controlled study. Setting Research laboratory. Subjects Adult female Sprague-Dawley rats. Interventions Rats were randomly assigned to one of five experimental groups: 1) acutely anesthetized control, 2) spontaneous breathing control, 3) spontaneously breathing control with administration of the nicotinamide adenine dinucleotide phosphate oxidase inhibitor, apocynin, 4) mechanically ventilated, and 5) mechanically ventilated with apocynin. Measurements and Main Results Apocynin attenuated MV-induced diaphragmatic oxidative stress, contractile dysfunction, and type I, type IIa, and type IIb/IIx myofiber atrophy. The apocynin-induced attenuation of MV-induced diaphragmatic atrophy and contractile dysfunction occurred in conjunction with a reduction in the small increase in nicotinamide adenine dinucleotide phosphate oxidase activity as well as the preservation of total glutathione levels, glutathione peroxidase protein abundance, and a decrease in the activation of the cysteine proteases, calpain-1 and caspase-3. Interestingly, independent of MV, apocynin increased diaphragmatic levels of calpastatin, an endogenous calpain inhibitor. Furthermore, treatment of skeletal muscle cells in culture (C2C12 myotubes) with apocynin resulted in an increase in both calpastatin mRNA levels and protein abundance. Conclusions Our results suggest that the protective effects of apocynin on the diaphragm during prolonged MV seem to be linked to both its functions as an antioxidant and role in cellular signaling regulating the cysteine protease inhibitor calpastatin. PMID:19242334

  5. Clinical Profile of Patients Requiring Prolonged Mechanical Ventilation and their Outcome in a Tertiary Care Medical ICU.

    PubMed

    Vora, Chakor S; Karnik, Niteen D; Gupta, Vishal; Nadkar, Milind Y; Shetye, Jaimala V

    2015-10-01

    An increasing number of patients require mechanical ventilation and there has been a proportional increase in patients needing prolonged mechanical ventilation (ventilated for ≥ 21 days, for atleast 6 hours per day). It accounts for about 10% of all mechanically ventilated patients. Although these patients represent a smaller proportion of intensive care unit (ICU) patients, they consume substantial ICU resources. We studied etiology, metabolic and clinical profile, complications and outcome of these patients. This was a prospective observational study in the medical ICUs of a tertiary hospital over 18 months. All patients above 12 years of age requiring prolonged invasive mechanical ventilation were recruited. Detailed clinical and laboratory records were noted. Sequential Organ Failure Assessment (SOFA) score was calculated on admission. Of a total 1150 patients who were admitted in ICU during study duration, 34.5% (n= 397) needed mechanical ventilation and 3.91% (n=45) required prolonged mechanical ventilation. Most common patient subsets were: acute inflammatory demyelinating polyneuropathy (AIDP) 28.50% (n=13), cerebro-vascular accident (CVA): 17.30% (n=8), tetanus 8.60% (n=4) and acute respiratory distress syndrome (ARDS) 6.50% (n=3). The mean age of patients was 32 years. Electrolyte imbalances observed were hypocalcaemia (84.44%), hypomagnesaemia (40.9%), hypokalemia (31.11%) and hypophosphatemia (23.8%). Ventilator-associated pneumonia (VAP) (53.33%) was the most frequent complication, followed by decubitus ulcers (40%) and deep vein thrombosis (8.89%). Mean duration of ICU stay was 57.02 days ± 44.73 days. Twenty six out of 45 patients (57.75%) were successfully weaned off ventilator support and discharged from the hospital. The SOFA score of patients who survived (mean 2.15) was lesser than that of patients who expired (mean 2.89) (p= 0.36, ns). The incidence of prolonged mechanical ventilation in our study was 3.91% of total 1150 ICU admissions and

  6. 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

  7. Risk factors for prolonged mechanical ventilation for children on ventricular assist device support.

    PubMed

    Prodhan, Parthak; Kalikivenkata, Giridhar; Tang, Xinyu; Thomas, Kassandra; Byrnes, Jonathan; Imamura, Michiaki; Jaquiss, Robert D B; Garcia, Xiomara; Frazier, Elizabeth A; Bhutta, Adnan T; Dyamenahalli, Umesh

    2015-05-01

    Patients with end-stage heart failure possess many attributes that place them at risk for prolonged mechanical ventilation (MV). However, there are only limited data on MV support among children after ventricular assist device (VAD) implantation. We report the duration of MV after VAD placement, indications for respiratory support in the postimplantation period, and associated patient factors. This single-center retrospective study included 43 consecutive children (aged <18 years) with end-stage heart failure who were supported with a VAD as a bridge to transplantation from January 2005 to December 2011. Multivariable analysis was performed using the multiple Poisson regression model for the duration of MV. Overall, 33% (n = 14) remained on MV until heart transplant or death. Of those requiring pre-VAD extracorporeal membrane oxygenation (ECMO) support, 63% (n = 12 of 19) remained on MV until heart transplant or death compared with 8% (n = 2 of 24) among those not on ECMO before VAD (p < 0.001). Patients with moderate or severe mitral regurgitation while on VAD support had 1.7-times more MV days compared with those with none or trivial on-VAD mitral regurgitation. In addition, previous support on ECMO, those with moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. Our results suggest that VAD recipients previously supported on ECMO, those with moderate or severe mitral regurgitation, moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. Future studies in larger cohorts are necessary to confirm the findings from this single-institutional experience. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  8. Nonthyroidal illness syndrome and prolonged mechanical ventilation in patients admitted to the ICU.

    PubMed

    Bello, Giuseppe; Pennisi, Mariano Alberto; Montini, Luca; Silva, Serena; Maviglia, Riccardo; Cavallaro, Fabio; Bianchi, Antonio; De Marinis, Laura; Antonelli, Massimo

    2009-06-01

    The effect of the nonthyroidal illness syndrome (NTIS) on the duration of mechanical ventilation (MV) has not been extensively investigated. This study aims to determine whether the NTIS is associated with the duration of MV in patients admitted to the ICU. We evaluated all patients admitted over a 6-year period to our ICU who underwent invasive MV and had measurement of serum free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH) performed in the first 4 days after ICU admission and, subsequently, at least every 8 days during the time they received MV. The primary outcome measure was prolonged MV (PMV), which was defined as dependence on MV for > 13 days. Two hundred sixty-four patients were included. Fifty-six patients (normal-hormone group) had normal thyroid function test results, whereas 208 patients (low-fT3 group) had, at least in one hormone dosage, low levels of fT3 with normal (n = 145)/low (n = 63) levels of fT4 and normal (n = 189)/low (n = 19) levels of TSH. Patients in the low-fT3 group showed significantly higher mortality and simplified acute physiology score II, and significantly longer duration of MV and ICU length of stay compared with the normal-hormone group. Two of the variables studied were associated with PMV, as follows: the NTIS (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.18 to 4.29; p = 0.01); and the presence of pneumonia (OR, 1.17; 95% CI, 1.06 to 3.01; p = 0.03). The NTIS represents a risk factor for PMV in mechanically ventilated, critically ill patients.

  9. Risk Factors Associated with Prolonged Mechanical Ventilation after Corrective Surgery for Tetralogy of Fallot.

    PubMed

    Li, Shengli; Zhang, Yajuan; Li, Shoujun; Wang, Xu; Zhang, Rongyuan; Lu, Zhongyuan; Yan, Jun

    2015-01-01

    This study examined early postoperative results to identify perioperative factors that are associated with prolonged mechanical ventilation (PMV) in tetralogy of Fallot (TOF) patients undergoing corrective surgery. We retrospectively examined the role of perioperative variables in determining the period of mechanical ventilatory support in TOF patients undergoing corrective surgery. A total of 821 patients were included in the study. The cohort was divided into a PMV group that included patients with >90th percentile for duration of mechanical ventilation and a non-PMV group which included all other patients. Non-PMV group consisted of 751 patients (454 males, 297 females; median age 12 months, interquartile range 8-19 months; mean weight 9.60 ± 2.98 kg). PMV group consisted of 70 patients (51 males, 19 females; median age 8 months, interquartile range 6.75-13 months; mean weight 8.64 ± 1.95 kg). No patients died in the non-PMV group compared with two deaths due to acute respiratory distress syndrome in the PMV group. Univariate risk factors for PMV included age, weight, left ventricular end-diastolic volume index (LVEDVI), McGoon ratio, Nakata index, previous palliative operations, cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, preoperative major aortopulmonary collateral arteries (MAPCAs) occlusion by coils in hybrid procedure, postoperative right ventricular/left ventricular systolic pressure ratio, central venous pressure (CVP), left atrial pressure (LAP), endotracheal reintubation, vasoactive-inotropic score (VIS), renal replacement therapy, and early-onset ventilator-associated pneumonia (VAP). In a multivariable model, age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, blood returning to left atrium during surgery as a surrogate marker for significant aortopulmonary collateral presence, and early-onset VAP were the independent risk factors for PMV. The risk factors for PMV were age, LVEDVI, McGoon ratio

  10. Test-retest reliability of expiratory abdominal compression with a handheld dynamometer in patients with prolonged mechanical ventilation

    PubMed Central

    Morino, Akira; Shida, Masahiro; Tanaka, Masashi; Sato, Kimihiro; Seko, Toshiaki; Ito, Shunsuke; Ogawa, Shunichi; Takahashi, Naoaki

    2015-01-01

    [Purpose] The present study aimed to examine the test-retest reliability of expiratory abdominal compression with a handheld dynamometer in patients with prolonged mechanical ventilation. [Subjects and Methods] We recruited 18 patients with prolonged mechanical ventilation. All patients had impaired consciousness. The mode of the ventilator was synchronized intermittent mandatory ventilation. The abdomen above the navel was vertically compressed using a handheld dynamometer in synchronization with expiration. Expiratory abdominal compression was performed two times. We measured the tidal volume during expiratory abdominal compression. There was an interval of 5 minutes between the first and second measurements. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were performed to examine the test-retest reliability of expiratory abdominal compression with a handheld dynamometer. [Results] The test-retest reliability of expiratory abdominal compression was excellent (ICC(1, 1): 0.987). Bland-Altman analysis showed that there was no fixed bias and no proportional bias. [Conclusion] The findings of this study suggest that expiratory abdominal compression with a handheld dynamometer is reliable and useful for patients with respiratory failure and prolonged mechanical ventilation. PMID:26311946

  11. Test-retest reliability of expiratory abdominal compression with a handheld dynamometer in patients with prolonged mechanical ventilation.

    PubMed

    Morino, Akira; Shida, Masahiro; Tanaka, Masashi; Sato, Kimihiro; Seko, Toshiaki; Ito, Shunsuke; Ogawa, Shunichi; Takahashi, Naoaki

    2015-07-01

    [Purpose] The present study aimed to examine the test-retest reliability of expiratory abdominal compression with a handheld dynamometer in patients with prolonged mechanical ventilation. [Subjects and Methods] We recruited 18 patients with prolonged mechanical ventilation. All patients had impaired consciousness. The mode of the ventilator was synchronized intermittent mandatory ventilation. The abdomen above the navel was vertically compressed using a handheld dynamometer in synchronization with expiration. Expiratory abdominal compression was performed two times. We measured the tidal volume during expiratory abdominal compression. There was an interval of 5 minutes between the first and second measurements. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were performed to examine the test-retest reliability of expiratory abdominal compression with a handheld dynamometer. [Results] The test-retest reliability of expiratory abdominal compression was excellent (ICC(1, 1): 0.987). Bland-Altman analysis showed that there was no fixed bias and no proportional bias. [Conclusion] The findings of this study suggest that expiratory abdominal compression with a handheld dynamometer is reliable and useful for patients with respiratory failure and prolonged mechanical ventilation.

  12. Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation

    PubMed Central

    Shin, Hong-Joon; Chang, Jin-Sun; Ahn, Seong; Kim, Tae-Ok; Park, Cheol-Kyu; Lim, Jung-Hwan; Oh, In-Jae; Kim, Yu-Il; Lim, Sung-Chul; Kim, Young-Chul

    2017-01-01

    Background For patients requiring prolonged mechanical ventilation (PMV), weaning is difficult and mortality is very high. PMV has been defined recently, by consensus, as constituting ≥21 consecutive days of mechanical ventilation (MV) for ≥6 hours per day. This study aimed to evaluate the clinical factors predicting weaning failure in patients undergoing PMV in medical intensive care unit (ICU). Methods We retrospectively reviewed the clinical and laboratory characteristics of 127 patients who received MV for more than 21 days in the medical ICU at Chonnam National University Hospital in South Korea between January 2005 and December 2014. Patients who underwent surgery or experienced trauma were excluded from this study. Results Among the 127 patients requiring PMV, 41 (32.3%) were successfully weaned from MV. The median age of the weaning failure group was higher than that of the weaning success group (74.0 vs. 70.0 years; P=0.003). The proportion of male patients was 58.5% in the weaning success group and 72.1% in the weaning failure group, respectively. The most common reasons for ICU admission were respiratory causes (66.1%) followed by cardiovascular causes (16.5%) in both groups. ICU mortality and in-hospital mortality rates were 55.1% and 55.9%, respectively. In the multivariate analysis, respiratory causes of ICU admission [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.29–12.30; P=0.016] and a high sequential organ failure assessment (SOFA) score on day 21 of MV (OR, 1.47; 95% CI, 1.17–1.85; P=0.001) were significantly associated with weaning failure in patients requiring PMV. The area under the receiver operating characteristic (ROC) curve of the SOFA score on day 21 of MV for predicting weaning failure was 0.77 (95% CI, 0.67–0.87; P=0.000). Conclusions Respiratory causes of ICU admission and a high SOFA score on day 21 of MV could be predictive of weaning failure in patients requiring PMV. PMID:28203417

  13. Upper extremity muscle tone and response of tidal volume during manually assisted breathing for patients requiring prolonged mechanical ventilation

    PubMed Central

    Morino, Akira; Shida, Masahiro; Tanaka, Masashi; Sato, Kimihiro; Seko, Toshiaki; Ito, Shunsuke; Ogawa, Shunichi; Yokoi, Yuka; Takahashi, Naoaki

    2015-01-01

    [Purpose] The aim of the present study was to examine, in patients requiring prolonged mechanical ventilation, if the response of tidal volume during manually assisted breathing is dependent upon both upper extremity muscle tone and the pressure intensity of manually assisted breathing. [Subjects] We recruited 13 patients on prolonged mechanical ventilation, and assessed their upper extremity muscle tone using the modified Ashworth scale (MAS). The subjects were assigned to either the low MAS group (MAS≤2, n=7) or the high MAS group (MAS≥3, n=6). [Methods] The manually assisted breathing technique was applied at a pressure of 2 kgf and 4 kgf. A split-plot ANOVA was performed to compare the tidal volume of each pressure during manually assisted breathing between the low and the high MAS groups. [Results] Statistical analysis showed there were main effects of the upper extremity muscle tone and the pressure intensity of the manually assisted breathing technique. There was no interaction between these factors. [Conclusion] Our findings reveal that the tidal volume during the manually assisted breathing technique for patients with prolonged mechanical ventilation depends upon the patient’s upper extremity muscle tone and the pressure intensity. PMID:26357431

  14. [Weaning from prolonged mechanical ventilation at 72 hours of spontaneous breathing].

    PubMed

    Villalba, Darío; Plotnikow, Gustavo; Feld, Viviana; Rivero Vairo, Noelia; Scapellato, José; Díaz Nielsen, Ernesto

    2015-01-01

    The aim of this study was to describe the population admitted to a weaning center (WC) to receive invasive mechanical ventilation (MV), analyze their evolution and identify weaning failure predictors. The medical records of 763 patients admitted to the respiratory care service in the period between May 2005 and January 2012 were reviewed; 372 were selected among 415 tracheotomized and mechanically ventilated. Different variables were analyzed as weaning failure predictors. The mean age of patients admitted was 69 years (SD 14.7), 57% were men. The median length of hospitalization in ICU was 33 days (IQR 26-46). Admission to ICU was due to medical causes in 86% of cases. During hospitalization in WC 186 (50%) patients achieved the successful weaning at a median of 13 days (interquartile range-IQR 5-38). A predictor of weaning failure was age. When we studied the subpopulation with partial disconnection of mechanical ventilation, we found a history of COPD and ageas predictors. Although 25% of the patients died, or required referral to a center of major complexity before 2 weeks of hospitalization, more than half of the patients were able to be removed permanently from the invasive mechanical ventilation (MV), this could support the care of chronic critical patients in MV and rehabilitation centers in Argentina because patients in these centers have a chance of weaning from MV, despite the high chances of developing complications.

  15. 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

  16. Mechanical ventilation in children.

    PubMed

    Kendirli, Tanil; Kavaz, Asli; Yalaki, Zahide; Oztürk Hişmi, Burcu; Derelli, Emel; Ince, Erdal

    2006-01-01

    Mechanical ventilation can be lifesaving, but > 50% of complications in conditions that require intensive care are related to ventilatory support, particularly if it is prolonged. We retrospectively evaluated the medical records of patients who had mechanical ventilation in the Pediatric Intensive Care Unit (PICU) during a follow-up period between January 2002-May 2005. Medical records of 407 patients were reviewed. Ninety-one patients (22.3%) were treated with mechanical ventilation. Ages of all patients were between 1-180 (median: 8) months. The mechanical ventilation time was 18.8 +/- 14.1 days. Indication of mechanical ventilation could be divided into four groups as respiratory failure (64.8%), cardiovascular failure (19.7%), central nervous system disease (9.8%) and safety airway (5.4%). Tracheostomy was performed in four patients. The complication ratio of mechanically ventilated children was 42.8%, and diversity of complications was as follows: 26.3% atelectasia, 17.5% ventilator-associated pneumonia, 13.1% pneumothorax, 5.4% bleeding, 4.3% tracheal edema, and 2.1% chronic lung disease. The mortality rate of mechanically ventilated patients was 58.3%, but the overall mortality rate in the PICU was 12.2%. In conclusion, there are few published epidemiological data on the follow-up results and mortality in infants and children who are mechanically ventilated.

  17. [Mechanical ventilator].

    PubMed

    Kimura, Akio; Hashimoto, S

    2009-07-01

    The development of the computer technology brought reform in the field of medical equipment. Originally the mechanical ventilator was an instrument only as for running by pressure and the tool that let you breathe. However, it has a function to assist a measurement (tidal volume, peek pressure, etc.) and to wean from a ventilator. There is a case to use a mechanical ventilator for after a chest surgical operation. After the operation without the complication, it seems that there is not the special administration. However, special respiratory management is necessary in case of chronic respiratory failure and acute lung injury, acute respiratory distress syndrome. Therefore I introduce a method to use a respirator after an operation in our institution.

  18. Effects of Lung Expansion Therapy on Lung Function in Patients with Prolonged Mechanical Ventilation.

    PubMed

    Chen, Yen-Huey; Yeh, Ming-Chu; Hu, Han-Chung; Lee, Chung-Shu; Li, Li-Fu; Chen, Ning-Hung; Huang, Chung-Chi; Kao, Kuo-Chin

    2016-01-01

    Common complications in PMV include changes in the airway clearance mechanism, pulmonary function, and respiratory muscle strength, as well as chest radiological changes such as atelectasis. Lung expansion therapy which includes IPPB and PEEP prevents and treats pulmonary atelectasis and improves lung compliance. Our study presented that patients with PMV have improvements in lung volume and oxygenation after receiving IPPB therapy. The combination of IPPB and PEEP therapy also results in increase in respiratory muscle strength. The application of IPPB facilitates the homogeneous gas distribution in the lung and results in recruitment of collapsed alveoli. PEEP therapy may reduce risk of respiratory muscle fatigue by preventing premature airway collapse during expiration. The physiologic effects of IPPB and PEEP may result in enhancement of pulmonary function and thus increase the possibility of successful weaning from mechanical ventilator during weaning process. For patients with PMV who were under the risk of atelectasis, the application of IPPB may be considered as a supplement therapy for the enhancement of weaning outcome during their stay in the hospital.

  19. Effects of Lung Expansion Therapy on Lung Function in Patients with Prolonged Mechanical Ventilation

    PubMed Central

    Chen, Yen-Huey; Yeh, Ming-Chu; Hu, Han-Chung; Lee, Chung-Shu; Li, Li-Fu; Chen, Ning-Hung; Huang, Chung-Chi; Kao, Kuo-Chin

    2016-01-01

    Common complications in PMV include changes in the airway clearance mechanism, pulmonary function, and respiratory muscle strength, as well as chest radiological changes such as atelectasis. Lung expansion therapy which includes IPPB and PEEP prevents and treats pulmonary atelectasis and improves lung compliance. Our study presented that patients with PMV have improvements in lung volume and oxygenation after receiving IPPB therapy. The combination of IPPB and PEEP therapy also results in increase in respiratory muscle strength. The application of IPPB facilitates the homogeneous gas distribution in the lung and results in recruitment of collapsed alveoli. PEEP therapy may reduce risk of respiratory muscle fatigue by preventing premature airway collapse during expiration. The physiologic effects of IPPB and PEEP may result in enhancement of pulmonary function and thus increase the possibility of successful weaning from mechanical ventilator during weaning process. For patients with PMV who were under the risk of atelectasis, the application of IPPB may be considered as a supplement therapy for the enhancement of weaning outcome during their stay in the hospital. PMID:27445550

  20. A randomized clinical trial of neurally adjusted ventilatory assist versus conventional weaning mode in patients with COPD and prolonged mechanical ventilation

    PubMed Central

    Kuo, Nai-Ying; Tu, Mei-Lien; Hung, Tsai-Yi; Liu, Shih-Feng; Chung, Yu-Hsiu; Lin, Meng-Chih; Wu, Chao-Chien

    2016-01-01

    Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients; the problem is especially obvious in COPD. Neutrally adjusted ventilatory assist (NAVA) can improve patient-ventilator asynchrony; however, the effect in COPD patients with prolonged mechanical ventilation is still unknown. The goals of this study are to evaluate the effect of NAVA and conventional weaning mode in patients with COPD during prolonged mechanical ventilation. Methods The study enrolled a total of 33 COPD patients with ventilator dependency for more than 21 days in the weaning center. A diaphragm electrical activity (Edi) catheter was inserted in patients within 24 hours after admission to the respiratory care center, and patients were randomly allocated to NAVA or conventional group. A spontaneous breathing trial was performed every 24 hours. The results correlated with the clinical parameters. Results There were significantly higher asynchrony incidence rates in the whole group after using Edi catheter (before vs post-Edi catheter insertion =60.6% vs 87.9%, P<0.001). Asynchrony index: before vs post-Edi catheter insertion =7.4%±8.5% vs 13.2%±13.5%, P<0.01. Asynchrony incidence: NAVA vs conventional =0% vs 84.2%, P<0.001. Asynchrony index: NAVA vs conventional =0 vs 11.9±11.2 (breath %), P<0.001. The most common asynchrony events were ineffective trigger and delayed trigger. Conclusion Compared to conventional mode, NAVA mode can significantly enhance respiratory monitoring and improve patient-ventilator interaction in COPD patients with prolonged mechanical ventilation in respiratory care center. PMID:27274216

  1. School Achievements, Behavioural Adjustments and Health at Nine Years of Age in a Population of Infants Who Were Born Preterm or Required Prolonged Mechanical Ventilation.

    ERIC Educational Resources Information Center

    Mohay, Heather; And Others

    The prevalence of subtle handicapping conditions, such as learning disabilities, behavior problems, and recurrent illness, in a population of 88 high-risk infants was investigated when the children reached 9 years of age. Infants had had birthweights of less than 1500 grams or had required prolonged mechanical ventilation in the neonatal period.…

  2. Inspiratory Muscle Strength Training in Infants With Congenital Heart Disease and Prolonged Mechanical Ventilation: A Case Report

    PubMed Central

    Bleiweis, Mark S.; Neel, Cimaron R.; Martin, A. Daniel

    2013-01-01

    Background and Purpose Inspiratory muscle strength training (IMST) has been shown to improve maximal pressures and facilitate ventilator weaning in adults with prolonged mechanical ventilation (MV). The purposes of this case report are: (1) to describe the rationale for IMST in infants with MV dependence and (2) to summarize the device modifications used to administer training. Case Description Two infants with congenital heart disease underwent corrective surgery and were referred for inspiratory muscle strength evaluation after repeated weaning failures. It was determined that IMST was indicated due to inspiratory muscle weakness and a rapid, shallow breathing pattern. In order to accommodate small tidal volumes of infants, 2 alternative training modes were devised. For infant 1, IMST consisted of 15-second inspiratory occlusions. Infant 2 received 10-breath sets of IMST through a modified positive end-expiratory pressure valve. Four daily IMST sets separated by 3 to 5 minutes of rest were administered 5 to 6 days per week. The infants' IMST tolerance was evaluated by vital signs and daily clinical reviews. Outcomes Maximal inspiratory pressure (MIP) and rate of pressure development (dP/dt) were the primary outcome measures. Secondary outcome measures included the resting breathing pattern and MV weaning. There were no adverse events associated with IMST. Infants generated training pressures through the adapted devices, with improved MIP, dP/dt, and breathing pattern. Both infants weaned from MV to a high-flow nasal cannula, and neither required subsequent reintubation during their hospitalization. Discussion This case report describes pediatric adaptations of an IMST technique used to improve muscle performance and facilitate weaning in adults. Training was well tolerated in 2 infants with postoperative weaning difficulty and inspiratory muscle dysfunction. Further systematic examination will be needed to determine whether IMST provides a significant performance

  3. [Modalities of mechanical ventilation].

    PubMed

    Subirana, M; Bazan, P

    2000-01-01

    Mechanical ventilation improves the symptoms and reduces complications of acute respiratory failure. Recent advances in microprocessor technology have increased the sophistication of mechanical ventilators, thus leading to new ventilation modalities. This article describes the ventilation modalities available, grouping them as conventional, alternative and new modalities. Conventional ventilation includes the most widely used modalities, alternative ventilation includes less frequently used modalities, and new ventilation modalities include recently introduced options that are available on the latest-generation mechanical ventilators.

  4. 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

    2016-11-29

    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.

  5. Agitation during prolonged mechanical ventilation at a long-term acute care hospital: risk factors, treatments, and outcomes.

    PubMed

    O'Connor, Heidi; Al-Qadheeb, Nada S; White, Alexander C; Thaker, Vishal; Devlin, John W

    2014-01-01

    The prevalence, risk factors, treatment practices, and outcomes of agitation in patients undergoing prolonged mechanical ventilation (PMV) in the long-term acute care hospital (LTACH) setting are not well understood. We compared agitation risk factors, management strategies, and outcomes between patients who developed agitation and those who did not, in LTACH patients undergoing PMV. Patients admitted to an LTACH for PMV over a 1-year period were categorized into agitated and nonagitated groups. The presence of agitation risk factors, management strategies, and relevant outcomes were extracted and compared between the 2 groups. A total of 80 patients were included, 41% (33) with agitation and 59% (47) without. Compared to the nonagitated group, the agitated group had a lower Sequential Organ Failure Assessment score (P < .0006), a greater transfer rate from an academic center (P = .05), a greater delirium frequency at both baseline (P = .04) and during admission (P < .001), and a greater rate of benzodiazepine discontinuation (P = .02). Although the use of scheduled antipsychotic (P = .0005) or restraint (P = .002) therapy was more common in the agitated group, use of benzodiazepines (P = .16), opioids (P = .11), or psychiatric evaluation (P = .90) was not. Weaning success, duration of LTACH stay, and daily costs were similar. Agitation among the LTACH patients undergoing PMV is associated with greater delirium and use of antipsychotics and restraints but does not influence weaning success or LTACH stay. Strategies focused on agitation prevention and treatment in this population need to be developed and formally evaluated. © The Author(s) 2013.

  6. Cross-talk between the calpain and caspase-3 proteolytic systems in the diaphragm during prolonged mechanical ventilation

    PubMed Central

    Nelson, W. Bradley; Ashley J., Smuder; Hudson, Matthew B.; Talbert, Erin E.; Powers, Scott K.

    2012-01-01

    OBJECTIVE Diaphragmatic weakness, due to both atrophy and contractile dysfunction, is a well-documented response following prolonged mechanical ventilation (MV). Evidence indicates that activation of the proteases calpain and caspase-3 are essential for MV-induced diaphragmatic weakness to occur. We tested the hypothesis that a regulatory cross-talk exists between calpain and caspase-3 in the diaphragm during prolonged MV. To test this prediction, we determined if selective pharmacological inhibition of calpain would prevent activation of caspase-3 and conversely, if selective inhibition of caspase-3 would abate calpain activation. DESIGN Animal study. SETTING University Research Laboratory SUBJECTS Female Sprague-Dawley rats INTERVENTIONS Animals were randomly divided into a control or one of three 12 hour MV groups that were treated with/without a selective pharmacological protease inhibitor: 1) control; 2) MV; 3) MV with a selective caspase-3 inhibitor; and 4) MV with a selective calpain inhibitor. MEASUREMENTS AND MAIN RESULTS Compared to control, MV resulted in calpain and caspase-3 activation in the diaphragm accompanied by atrophy of type I, type IIa, and type IIx/IIb fibers. Independent inhibition of either calpain or caspase-3 prevented this MV-induced atrophy. Pharmacological inhibition of calpain prevented MV-induced activation of diaphragmatic caspase-3 and inhibition of caspase-3 prevented activation of diaphragmatic calpain. Further, calpain inhibition also prevented the activation of caspase-9 and caspase-12, along with the cleavage of Bid to tBid, all upstream signals for caspase-3 activation. Lastly, caspase-3 inhibition prevented the MV-induced degradation of the endogenous calpain inhibitor, calpastatin. CONCLUSIONS Collectively, these results indicate that MV-induced diaphragmatic atrophy is dependent upon the activation of both calpain and caspase-3. Importantly, these findings provide the first experimental evidence in diaphragm muscle that

  7. Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia.

    PubMed

    Bairdain, Sigrid; Dodson, Brenda; Zurakowski, David; Waisel, David B; Jennings, Russell W; Boretsky, Karen R

    2015-11-01

    Infants with long-gap esophageal atresia (LGEA) undergo repeated thoracotomies for staged surgical repair known as the Foker process (FP). Associated prolonged mechanical ventilation results in exposure to high doses of opioids and benzodiazepines, and prolonged weaning times and ICU stays. The aim of this study was to determine the effectiveness of short-term paravertebral nerve block (PVNB) catheters in reducing opioid/benzodiazepine exposure and effects on clinical variables. The medical records of seventeen infants were retrospectively reviewed; 11 with PVNB and six without (CG). PVNB were placed using ultrasound-guidance and chloroprocaine infusions implemented in the ICU. Opioids and benzodiazepines were administered via the protocol for 5 days following thoracotomies for Foker-I and Foker-II. Foker-I: Average reduction in morphine and midazolam consumption was 36% (2.18 vs 3.40 mg·kg(-1) ·day(-1) ; P < 0.001) and 31% (2.25 vs 3.25 mg·kg(-1) ·day(-1) ; P = 0.033), respectively, in the PVNB compared with CG. Foker-II: Average reduction in morphine and midazolam consumption was 39% (3.19 vs 5.27 mg·kg(-1) ·day(-1) ) and 38% (3.46 mg·kg(-1) ·day(-1) vs 5.62; P < 0.001), respectively in the PVNB compared with CG. 24-h prior to extubation: Average reduction in morphine and midazolam consumption was 50% (2.91 vs 5.85 mg·kg(-1) ·24 h(-1) ; p = 0.023) and 61% (2.27 vs 5.83 mg·kg(-1) ·24 h(-1) ; P = 0.004), respectively, in the PVNB compared with CG. Infusion wean time, (independence from opioid/midazolam infusions) following extubation was 5 days in the PVNB group and 15 days in CG (P = 0.005). Median ICU stay (IQR) was 40 days (34-45 days) in PVNB patients and 71 days (42-106 days) in controls (P = 0.02). PVNB catheters were left an average of 7 days and there were no complications associated with the nerve blocks. Short-term PVNB placement decreases opioid and benzodiazepine exposure, weaning days and ICU stay in infants

  8. Outcomes of prolonged mechanic ventilation: a discrimination model based on longitudinal health insurance and death certificate data.

    PubMed

    Lu, Hsin-Ming; Chen, Likwang; Wang, Jung-Der; Hung, Mei-Chuan; Lin, Ming-Shian; Yan, Yuan-Horng; Chen, Cheng-Ren; Fan, Po-Sheng; Huang, Lynn Chu; Kuo, Ken N

    2012-04-25

    This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV. This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients. Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003. Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near

  9. Cost per QALY (Quality-Adjusted Life Year) and Lifetime Cost of Prolonged Mechanical Ventilation in Taiwan

    PubMed Central

    Hung, Mei-Chuan; Lu, Hsin-Ming; Chen, Likwang; Lin, Ming-Shian; Chen, Cheng-Ren; Yu, Chong-Jen; Wang, Jung-Der

    2012-01-01

    Introduction Patients who require prolonged mechanical ventilation (PMV) are increasing and producing financial burdens worldwide. This study determines the cost per QALY (quality-adjusted life year), out-of-pocket expenses, and lifetime costs for PMV patients stratified by underlying diseases and cognition levels. Methods A nationwide sample of 50,481 patients with continual mechanical ventilation for more than 21 days was collected during 1997–2007. After stratifying the patients according to specific diagnoses, a latent class analysis (LCA) was performed to categorise PMV patients with multiple co-morbidities into several homogeneous groups. The survival functions were estimated for individual groups using the Kaplan-Meier method and extrapolated to 300 months through a semi-parametric method. The survival functions were adjusted using an EQ-5D utility value derived from a convenience sample of 142 PMV patients to estimate quality-adjusted life expectancies (QALE). Another convenience sample of 165 patients was used to estimate the out-of-pocket expenses. The lifetime expenditures paid by the single-payer National Health Insurance (NHI) system and patients' families were estimated by multiplying average monthly expenditures by the survival probabilities and summing the values over lifetime. Results PMV therapy costs more than 100,000 U.S. dollars (USD) per QALY for all patients with poor cognition. For patients with partial cognition, PMV therapy costs less than 56,000 USD per QALY for those with liver cirrhosis, intracranial or spinal cord injuries, and 57,000–69,000 USD for patients with multiple co-morbidities under age of 65. The average lifetime cost of PMV was usually below 56,000 USD. The out-of-pocket expenses were often more than one-third of the total cost of treatment. Conclusions PMV treatment for patients with poor cognition would cost more than 5 times Taiwan's GDP (gross domestic products), or less cost-effective. The out-of-pocket expenses

  10. Mechanical Ventilation

    MedlinePlus

    ... cared for in a hospital’s intensive care unit (ICU). People who need a ventilator for a longer time may be in a regular unit of a hospital, a rehabilitation facility, or cared for at home. Why are ...

  11. [Weaning from prolonged mechanical ventilation in neurological weaning units: an evaluation of the German Working Group for early Neurorehabilitation].

    PubMed

    Oehmichen, F; Ketter, G; Mertl-Rötzer, M; Platz, T; Puschendorf, W; Rollnik, J D; Schaupp, M; Pohl, M

    2012-10-01

    A significant proportion of patients with long-term mechanical ventilation (MV) and difficult or prolonged weaning suffer from primary or secondary neurological conditions and concomitant functional disorders, in addition to respiratory problems. Therefore, these patients are treated in neurological weaning departments. Using a questionnaire members of the German Working Group for early neurorehabilitation were interviewed with respect to the structure of weaning facilities, weaning strategies, patient characteristics and treatment outcome of patients admitted for weaning in 2009. In the year 2009 a total of 1,486 patients were admitted to 7 participating neurological weaning units. The primary diagnosis was a neurological condition in 97.5% of the patients. In 62.9% of the patients the neurological condition was considered to be primarily responsible for the MV, 22.8% demonstrated pulmonary factors and for 3.0% a cardiac condition was determined to be decisive. In 5.0% of the patients it was not possible to ascertain a single cause or factor. Weaning was successful in 69.8% of all cases, 64.9% (965 patients) were released from the facility without MV, 274 patients (18.4%) were released with MV, 61.3% of these (168 patients) were referred to other rehabilitation facilities or into the care of the family physician and 38.7% (106 patients) were transferred to other hospitals due to special medical problems. The total mortality rate was 16.6% (247 patients deceased). In this first comprehensive evaluation of German neurological weaning centers for patients with long-term MV, structures and treatment outcomes were compared with recent results from the literature.

  12. Diaphragmatic dysfunction in mechanical ventilation.

    PubMed

    Haitsma, Jack J

    2011-04-01

    It has become clear from experimental data that prolonged mechanical ventilation can induce diaphragm dysfunction, also known as ventilator-induced diaphragm dysfunction. In this article we will discuss most recent understanding on ventilator-induced diaphragm dysfunction and data on diaphragm dysfunction in patients. Over the last year several studies confirmed the existence of diaphragm dysfunction in patients. Known atrophy pathways are activated in patients undergoing prolonged conventional ventilation resulting in muscle proteolysis and a decrease in myofiber content. The loss of diaphragm force is time-dependent, but current data do not distinguish between the role played by other factors involved in diaphragm dysfunction. Diaphragm dysfunction occurs in patients, especially when ventilated with controlled modes of ventilation that minimize diaphragm activity. Time on the ventilator seems to be one of the biggest risk factors resulting in difficulties in weaning patients and prolonging time on the ventilator. Future trials should investigate whether improved patient-ventilator synchrony can reduce ventilator-induced diaphragm dysfunction and decrease weaning failure.

  13. 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

  14. Variable mechanical ventilation.

    PubMed

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

    2017-01-01

    To review the literature on the use of variable mechanical ventilation and the main outcomes of this technique. 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". A total of 36 studies were selected. Of these, 24 were original studies, including 21 experimental studies and three clinical studies. 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.

  15. Adapting the ABCDEF Bundle to Meet the Needs of Patients Requiring Prolonged Mechanical Ventilation in the Long-Term Acute Care Hospital Setting: Historical Perspectives and Practical Implications.

    PubMed

    Balas, Michele C; Devlin, John W; Verceles, Avelino C; Morris, Peter; Ely, E Wesley

    2016-02-01

    When robust clinical trials are lacking, clinicians are often forced to extrapolate safe and effective evidence-based interventions from one patient care setting to another. This article is about such an extrapolation from the intensive care unit (ICU) to the long-term acute care hospital (LTACH) setting. Chronic critical illness is an emerging, disabling, costly, and yet relatively silent epidemic that is central to both of these settings. The number of chronically critically ill patients requiring prolonged mechanical ventilation is expected to reach unprecedented levels over the next decade. Despite the prevalence, numerous distressing symptoms, and exceptionally poor outcomes associated with chronic critical illness, to date there is very limited scientific evidence available to guide the care and management of this exceptionally vulnerable population, particularly in LTACHs. Recent studies conducted in the traditional ICU setting suggest interprofessional, multicomponent strategies aimed at effectively assessing, preventing, and managing pain, agitation, delirium, and weakness, such as the ABCDEF bundle, may play an important role in the recovery of the chronically critically ill. This article reviews what is known about the chronically critically ill, provide readers with some important historical perspectives on the ABCDEF bundle, and address some controversies and practical implications of adopting the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting. We believe developing new and better ways of addressing both the science and organizational aspects of managing the common and distressing symptoms associated with chronic critical illness and prolonged mechanical ventilation will ultimately improve the quality of life for the many patients and families admitted to LTACHs annually.

  16. Comparison of changes in tidal volume associated with expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation

    PubMed Central

    Morino, Akira; Shida, Masahiro; Tanaka, Masashi; Sato, Kimihiro; Seko, Toshiaki; Ito, Shunsuke; Ogawa, Shunichi; Takahashi, Naoaki

    2015-01-01

    [Purpose] This study was designed to compare and clarify the relationship between expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation, with a focus on tidal volume. [Subjects and Methods] The subjects were 18 patients on prolonged mechanical ventilation, who had undergone tracheostomy. Each patient received expiratory rib cage compression and expiratory abdominal compression; the order of implementation was randomized. Subjects were positioned in a 30° lateral recumbent position, and a 2-kgf compression was applied. For expiratory rib cage compression, the rib cage was compressed unilaterally; for expiratory abdominal compression, the area directly above the navel was compressed. Tidal volume values were the actual measured values divided by body weight. [Results] Tidal volume values were as follows: at rest, 7.2 ± 1.7 mL/kg; during expiratory rib cage compression, 8.3 ± 2.1 mL/kg; during expiratory abdominal compression, 9.1 ± 2.2 mL/kg. There was a significant difference between the tidal volume during expiratory abdominal compression and that at rest. The tidal volume in expiratory rib cage compression was strongly correlated with that in expiratory abdominal compression. [Conclusion] These results indicate that expiratory abdominal compression may be an effective alternative to the manual breathing assist procedure. PMID:26311963

  17. Effectiveness of surgical rib fixation on prolonged mechanical ventilation in patients with traumatic rib fractures: A propensity score-matched analysis.

    PubMed

    Wada, Tomoki; Yasunaga, Hideo; Inokuchi, Ryota; Matsui, Hiroki; Matsubara, Takehiro; Ueda, Yoshihiro; Gunshin, Masataka; Ishii, Takeshi; Doi, Kent; Kitsuta, Yoichi; Nakajima, Susumu; Fushimi, Kiyohide; Yahagi, Naoki

    2015-12-01

    We investigated whether surgical rib fixation improved outcomes in patients with traumatic rib fractures. This was a retrospective study using a Japanese administrative claim and discharge database. We included patients with traumatic rib fractures admitted to hospitals where surgical rib fixation was available from July 1 2010, to March 31, 2013. We detected patients who underwent surgical rib fixation within 10 days of hospital admission (surgical group) and those who did not (control group). The main outcome was prolonged mechanical ventilation, defined as that performed for 5 or more days, or death within 28 days. One-to-four propensity score matching was performed between the 2 groups with adjustment for possible confounders. Among 4577 eligible patients, 90 (2.0%) underwent the surgical rib fixation. After the matching, we obtained 84 and 336 patients in the surgical and control groups, respectively. Logistic regression analyses showed that the surgical group was significantly less likely to receive prolonged mechanical ventilation or die within 28 days than the control group (22.6% vs 33.3%; odds ratio, 0.59; 95% confidence interval, 0.36-0.96; P=.034). Surgical rib fixation within 10 days of hospital admission may improve outcomes in patients with traumatic rib fractures. Copyright © 2015 Elsevier Inc. All rights reserved.

  18. Pulmonary mechanics during mechanical ventilation.

    PubMed

    Henderson, William R; Sheel, A William

    2012-03-15

    The use of mechanical ventilation has become widespread in the management of hypoxic respiratory failure. Investigations of pulmonary mechanics in this clinical scenario have demonstrated that there are significant differences in compliance, resistance and gas flow when compared with normal subjects. This paper will review the mechanisms by which pulmonary mechanics are assessed in mechanically ventilated patients and will review how the data can be used for investigative research purposes as well as to inform rational ventilator management.

  19. Patient-ventilator dyssynchrony during assisted invasive mechanical ventilation.

    PubMed

    Murias, G; Villagra, A; Blanch, L

    2013-04-01

    Patient-ventilator dyssynchrony is common during mechanical ventilation. Dyssynchrony decreases comfort, prolongs mechanical ventilation and intensive care unit stays, and might lead to worse outcome. Dyssynchrony can occur during the triggering of the ventilator, the inspiration period after triggering, the transition from inspiration to expiration, and the expiratory phase. The most common dyssynchronies are delayed triggering, autotriggering, ineffective inspiratory efforts (which can occur at any point in the respiratory cycle), mismatch between the patient's and ventilator's inspiratory times, and double triggering. At present, the detection of dyssynchronies usually depends on healthcare staff observing ventilator waveforms; however, performance is suboptimal and many events go undetected. To date, technological complexity has made it impossible to evaluate patient-ventilator synchrony throughout the course of mechanical ventilation. Studies have shown that a high index of dyssynchrony may increase the duration of mechanical ventilation. Better training, better ventilatory modes, and/or computerized systems that permit better synchronization of patients' demands and ventilator outputs are necessary to improve patient-ventilator synchrony.

  20. Prolonged mechanical ventilation in critically ill patients: epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit.

    PubMed

    Lone, Nazir I; Walsh, Timothy S

    2011-01-01

    The number of patients requiring prolonged mechanical ventilation (PMV) is likely to increase. Transferring patients to specialised weaning units may improve outcomes and reduce costs. The aim of this study was to establish the incidence and outcomes of PMV in a UK administrative health care region without a dedicated weaning unit, and model the potential impact of establishing a dedicated weaning unit. A retrospective cohort study was undertaken using a database of admissions to three intensive care units (ICU) in a UK region from 2002 to 2006. Using a 21 day cut-off to define PMV, incidence was calculated using all ICU admissions and ventilated ICU admissions as denominators. Outcomes for the PMV cohort (mortality and hospital resource use) were compared with the non-PMV cohort. Length of ICU stay beyond 21 days was used to model the effect of establishing a weaning unit in terms of unit occupancy rates, admission refusal rates, and healthcare costs. Out of 8290 ICU admission episodes, 7848 were included in the analysis. Mechanical ventilation was required during 5552 admission episodes, of which 349 required PMV. The incidence of PMV was 4.4 per 100 ICU admissions, and 6.3 per 100 ventilated ICU admissions. PMV patients used 29.1% of all general ICU bed days, spent longer in hospital after ICU discharge than non-PMV patients (median 17 vs 7 days, P < 0.001) and had higher hospital mortality (40.3% vs 33.8%, P = 0.02). For the region, in which about 70 PMV patients were treated each year, a weaning unit with a capacity of three beds appeared most cost efficient, resulting in an occupancy rate of 73%, admission refusal rate at 21 days of 36%, and potential cost saving of £344,000 (€418,000) using UK healthcare tariffs. One in every sixteen ventilated patients requires PMV in our region and this group use a substantial amount of health care resource. Establishing a weaning unit would potentially reduce acute bed occupancy by 8-10% and could reduce overall

  1. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours.

    PubMed

    Templeton, Maie; Palazzo, Mark G A

    2007-11-01

    This study aimed to determine the impact of providing chest physiotherapy after routine clinical assessment on the duration of mechanical ventilation, outcome and intensive care length of stay. Single-centre, single-blind, prospective, randomised, controlled trial in a university hospital general intensive care unit. 180 patients requiring mechanical ventilation for more than 48 h. Patients randomly allocated, one group receiving physiotherapy as deemed appropriate by physiotherapists after routine daily assessments and another group acting as controls were limited to receiving decubitus care and tracheal suctioning. Primary endpoints were initial time to become ventilator-free, secondary endpoints included intensive care unit (ICU) and hospital mortality and ICU length of stay. Kaplan-Meier analysis censored for death revealed a significant prolongation of median time to become ventilator-free among patients receiving physiotherapy (p=0.047). The time taken for 50% of patients (median time) to become ventilator-free was 15 and 11 days, respectively, for physiotherapy and control groups. There were no differences between groups in ICU or hospital mortality rates, or length of ICU stay. The number of patients needing re-ventilation for respiratory reasons was similar in both groups.

  2. Incidence, life expectancy and prognostic factors in cancer patients under prolonged mechanical ventilation: a nationwide analysis of 5,138 cases during 1998-2007.

    PubMed

    Shih, Chih-Yuan; Hung, Mei-Chuan; Lu, Hsin-Ming; Chen, Likwang; Huang, Sheng-Jean; Wang, Jung-Der

    2013-07-22

    This study is aimed at determining the incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE) and prognostic factors in patients with cancer in different organ systems undergoing prolonged mechanical ventilation (PMV). We used data from the National Health Insurance Research Database of Taiwan from 1998 to 2007 and linked it with the National Mortality Registry to ascertain mortality. Subjects who received PMV, defined as having undergone mechanical ventilation continuously for longer than 21 days, were enrolled. The incidence of cancer patients requiring PMV was calculated, with the exception of patients with multiple cancers. The life expectancies and QALE of patients with different types of cancer were estimated. Quality-of-life data were taken from a sample of 142 patients who received PMV. A multivariable proportional hazards model was constructed to assess the effect of different prognostic factors, including age, gender, type of cancer, metastasis, comorbidities and hospital levels. Among 9,011 cancer patients receiving mechanical ventilation for more than 7 days, 5,138 undergoing PMV had a median survival of 1.37 months (interquartile range [IQR], 0.50 to 4.57) and a 1-yr survival rate of 14.3% (95% confidence interval [CI], 13.3% to 15.3%). The incidence of PMV was 10.4 per 100 ICU admissions. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years, with estimated QALE ranging from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognition, respectively. Cancer of liver (hazard ratio [HR], 1.55; 95% CI, 1.34 to 1.78), lung (HR, 1.45; 95% CI, 1.30 to 1.41) and metastasis (HR, 1.53; 95% CI, 1.42 to 1.65) were found to predict shorter survival independently. Cancer patients requiring PMV had poor long-term outcomes. Palliative care should be considered early in these patients, especially when metastasis has occurred.

  3. Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV.

    PubMed

    Di Mussi, Rosa; Spadaro, Savino; Mirabella, Lucia; Volta, Carlo Alberto; Serio, Gabriella; Staffieri, Francesco; Dambrosio, Michele; Cinnella, Gilda; Bruno, Francesco; Grasso, Salvatore

    2016-01-05

    Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency. Patients previously ventilated with controlled mechanical ventilation for 72 hours or more were randomized to be ventilated for 48 hours with pressure support ventilation (n =12) or neurally adjusted ventilatory assist (n = 13). Neuro-ventilatory efficiency (tidal volume/diaphragmatic electrical activity) and neuro-mechanical efficiency (pressure generated against the occluded airways/diaphragmatic electrical activity) were measured during three spontaneous breathing trials (0, 24 and 48 hours). Breathing pattern, diaphragmatic electrical activity and pressure time product of the diaphragm were assessed every 4 hours. In patients randomized to neurally adjusted ventilator assist, neuro-ventilatory efficiency increased from 27 ± 19 ml/μV at baseline to 62 ± 30 ml/μV at 48 hours (p <0.0001) and neuro-mechanical efficiency increased from 1 ± 0.6 to 2.6 ± 1.1 cmH2O/μV (p = 0.033). In patients randomized to pressure support ventilation, these did not change. Electrical activity of the diaphragm, neural inspiratory time, pressure time product of the diaphragm and variability of the breathing pattern were significantly higher in patients ventilated with neurally adjusted ventilatory assist. The asynchrony index was 9.48 [6.38- 21.73] in patients ventilated with pressure support ventilation and 5.39 [3.78- 8.36] in patients ventilated with neurally adjusted ventilatory assist (p = 0.04). After prolonged controlled mechanical ventilation, neurally adjusted ventilator assist improves diaphragm efficiency whereas pressure support ventilation does not. ClinicalTrials.gov study registration: NCT02473172, 06/11/2015.

  4. Conventional mechanical ventilation

    PubMed Central

    Tobias, Joseph D.

    2010-01-01

    The provision of mechanical ventilation for the support of infants and children with respiratory failure or insufficiency is one of the most common techniques that are performed in the Pediatric Intensive Care Unit (PICU). Despite its widespread application in the PICUs of the 21st century, before the 1930s, respiratory failure was uniformly fatal due to the lack of equipment and techniques for airway management and ventilatory support. The operating rooms of the 1950s and 1960s provided the arena for the development of the manual skills and the refinement of the equipment needed for airway management, which subsequently led to the more widespread use of endotracheal intubation thereby ushering in the era of positive pressure ventilation. Although there seems to be an ever increasing complexity in the techniques of mechanical ventilation, its successful use in the PICU should be guided by the basic principles of gas exchange and the physiology of respiratory function. With an understanding of these key concepts and the use of basic concepts of mechanical ventilation, this technique can be successfully applied in both the PICU and the operating room. This article reviews the basic physiology of gas exchange, principles of pulmonary physiology, and the concepts of mechanical ventilation to provide an overview of the knowledge required for the provision of conventional mechanical ventilation in various clinical arenas. PMID:20927268

  5. Post-traumatic stress symptoms in Guillain-Barré syndrome patients after prolonged mechanical ventilation in ICU: a preliminary report.

    PubMed

    Le Guennec, Loïc; Brisset, Marion; Viala, Karine; Essardy, Fatiha; Maisonobe, Thierry; Rohaut, Benjamin; Demeret, Sophie; Bolgert, Francis; Weiss, Nicolas

    2014-09-01

    Thirty percent of Guillain-Barré syndrome (GBS) patients require mechanical ventilation (MV) in intensive care unit (ICU). Post-traumatic stress disorder (PTSD) is found in ICU survivors, and the traumatic aspects of intubation and MV have been previously reported as risk factors for PTSD after ICU. Our objective was to determine long-term PTSD or post-traumatic stress symptoms (PTSS) in GBS patients after prolonged MV in ICU. We assessed GBS patients who had MV for more than 2 months. PTSD was assessed using Horowitz Impact of Event Scale (IES), IES-Revisited (IES-R), and the Post-traumatic CheckList Scale; functional outcome using Rankin and Barthel scales; quality of life (QoL) using Nottingham Health Profile (NHP) and 36-Item Short Form Health Survey (SF-36) and depression using Hospital Anxiety and Depression Scale (HAD) and Beck questionnaire. Thirteen patients could be identified and analyzed. They had only mild disability. They were neither anxious nor depressed with an anxiety HAD at 5 (4-11.5), a depression HAD at 1 (0-3.5) and a Beck at 1 (0-5). QoL was mildly decreased in our population with a NHP at 78.5 (12.8-178.8) and mild decreased SF-36. Compared with the French population, the SF-36 sub-categories were, however, not statistically different. Twenty-two percentage of our 13 patients had PTSD and PTSS with a Horowitz IES at 12 (2-29), and an IES-R at 16 (2-34.5). Although severe GBS patients requiring prolonged MV had good functional recovery and no difference in QoL, they had a high incidence of PTSS. © 2014 Peripheral Nerve Society.

  6. Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: a comparison between artificial neural networks and logistic regression models

    PubMed Central

    Mendes, Renata G.; de Souza, César R.; Machado, Maurício N.; Correa, Paulo R.; Di Thommazo-Luporini, Luciana; Arena, Ross; Myers, Jonathan; Pizzolato, Ednaldo B.

    2015-01-01

    Introduction In coronary artery bypass (CABG) surgery, the common complications are the need for reintubation, prolonged mechanical ventilation (PMV) and death. Thus, a reliable model for the prognostic evaluation of those particular outcomes is a worthwhile pursuit. The existence of such a system would lead to better resource planning, cost reductions and an increased ability to guide preventive strategies. The aim of this study was to compare different methods – logistic regression (LR) and artificial neural networks (ANNs) – in accomplishing this goal. Material and methods Subjects undergoing CABG (n = 1315) were divided into training (n = 1053) and validation (n = 262) groups. The set of independent variables consisted of age, gender, weight, height, body mass index, diabetes, creatinine level, cardiopulmonary bypass, presence of preserved ventricular function, moderate and severe ventricular dysfunction and total number of grafts. The PMV was also an input for the prediction of death. The ability of ANN to discriminate outcomes was assessed using receiver-operating characteristic (ROC) analysis and the results were compared using a multivariate LR. Results The ROC curve areas for LR and ANN models, respectively, were: for reintubation 0.62 (CI: 0.50–0.75) and 0.65 (CI: 0.53–0.77); for PMV 0.67 (CI: 0.57–0.78) and 0.72 (CI: 0.64–0.81); and for death 0.86 (CI: 0.79–0.93) and 0.85 (CI: 0.80–0.91). No differences were observed between models. Conclusions The ANN has similar discriminating power in predicting reintubation, PMV and death outcomes. Thus, both models may be applicable as a predictor for these outcomes in subjects undergoing CABG. PMID:26322087

  7. [Effect of propofol-based combined anesthesia on the development of adaptive mechanisms to the prolonged one-lung artificial ventilation].

    PubMed

    Kurilova, O A; Vyzhigina, M A; Sandrikov, V A; Mizikov, V M; Kulagina, T Iu; Zhukova, S G; Parshin, V D

    2010-01-01

    The paper deals with the assessment of the adequacy and safety of multicomponent anesthesia based on propofol at lung surgery requiring one-lung ventilation (OLV) in patients with chronic respiratory diseases and with the evaluation of the effect of propofol on the development of adaptive mechanisms in various ventilation modalities in thoracic surgery. The pressor, resistive, and volume characteristics of pulmonary blood flow, systemic and intracardiac hemodynamics under artificial ventilation (AV) and OLV of a duration of up to 1.5 hours by a combination of pulmonal and transpulmonal thermodilution on a PiCCO plus device with a VOLEF attachment were compared. Multicomponent balanced anesthesia based on continuous graduated propofol infusion provides adequate protection of patients during thoracic operations, including those with concomitant respiratory abnormality.

  8. Understanding mechanical ventilators.

    PubMed

    Chatburn, Robert L

    2010-12-01

    The respiratory care academic community has not yet adopted a standardized system for classifying and describing modes of ventilation. As a result, there is enough confusion that patient care, clinician education and even ventilator sales are all put at risk. This article summarizes a ventilator mode taxonomy that has been extensively published over the last 15 years. Specifically, the classification system has three components: a description of the control variables within breath; a description of the sequence of mandatory and spontaneous breaths; and a specification for the targeting scheme. This three-level specification provides scalability of detail to make the mode description appropriate for the particular need. At the bedside, we need only refer to a mode briefly using the first or perhaps first and second components. To distinguish between similar modes and brand names, we would need to include all components. This taxonomy uses the equation of motion for the respiratory system as the underlying theoretical framework. All terms relevant to describing modes of mechanical ventilation are defined in an extensive appendix.

  9. Electrical impedance tomography monitoring in acute respiratory distress syndrome patients with mechanical ventilation during prolonged positive end-expiratory pressure adjustments.

    PubMed

    Hsu, Chia-Fu; Cheng, Jen-Suo; Lin, Wei-Chi; Ko, Yen-Fen; Cheng, Kuo-Sheng; Lin, Sheng-Hsiang; Chen, Chang-Wen

    2016-03-01

    The time required to reach oxygenation equilibrium after positive end-expiratory pressure (PEEP) adjustments in mechanically ventilated patients with acute respiratory distress syndrome (ARDS) is unclear. We used electrical impedance tomography to elucidate gas distribution and factors related to oxygenation status following PEEP in patients with ARDS. Nineteen mechanically ventilated ARDS patients were placed on baseline PEEP (PEEPB) for 1 hour, PEEPB - 4 cmH2O PEEP (PEEPL) for 30 minutes, and PEEPB + 4 cmH2O PEEP (PEEPH) for 1 hour. Tidal volume and respiratory rate were similar. Impedance changes, respiratory parameters, and arterial blood gases were measured at baseline, 5 minutes, and 30 minutes after PEEPL, and 5 minutes, 15 minutes, 30 minutes, and 1 hour after PEEPH. PaO2/fraction of inspired oxygen (P/F ratio) decreased quickly from PEEPB to PEEPL, and stabilized 5 minutes after PEEPL. However the P/F ratio progressively increased from PEEPL to PEEPH, and a significantly higher P/F ratio and end-expiratory lung impedance were found at 60 minutes compared to 5 minutes after PEEPH. The end-expiratory lung impedance level significantly correlated with P/F ratio (p < 0.001). With increasing PEEP, dorsal ventilation significantly increased; however, regional ventilation did not change over time with PEEP level. Late improvements in oxygenation following PEEP escalation are probably due to slow recruitment in ventilated ARDS patients. Electrical impedance tomography may be an appropriate tool to assess recruitment and oxygenation status in patients with changes in PEEP. Copyright © 2015. Published by Elsevier B.V.

  10. Adverse hemodynamic effects of lateral rotation during mechanical ventilation.

    PubMed

    Hamlin, Shannan K; Hanneman, Sandra K; Wachtel, Sheryln; Gusick, Gary

    2008-01-01

    Turning critically ill, mechanically ventilated patients every 2 hours is a fundamental nursing intervention to reduce the negative impact of prolonged immobility from preventable pulmonary complications such as ventilator-associated pneumonia and atelectasis. Unfortunately, when coupled with positive pressure ventilation, the benefits of turning may come at the expense of cardiovascular function. Clinicians should closely monitor the hemodynamic response to turning mechanically ventilated patients, and if compromise is observed, the degree and duration of compromise may provide guidance to the appropriate intervention.

  11. Prolonged ventilator dependence: perspective of the chronic obstructive pulmonary disease patient.

    PubMed

    Forbes, Maryann O'Shea

    2007-08-01

    The purpose of this qualitative inquiry was to examine the meaning of prolonged mechanical ventilation from the perspective of the patient with a diagnosis of chronic obstructive pulmonary disease (COPD). Interviews were conducted with four individuals with a diagnosis of COPD who had experienced long-term ventilator dependence. Participants were asked to reflect on their experiences while they were ventilator dependent, and their narratives were utilized as text for hermeneutical analysis. The study's findings describe three distinct phases experienced by the participants, beginning with intubation and lasting until well after discharge from the hospital. The support of nurses was an important aspect of maintaining hope for the participants. The study revealed that prolonged mechanical ventilation had a profound impact on COPD patients and their sense of self. Postdischarge psychological support and follow-up with survivors of this experience is warranted.

  12. Home Mechanical Ventilation in Children.

    PubMed

    Preutthipan, Aroonwan

    2015-09-01

    The number of children dependent on home mechanical ventilation has been reported to be increasing in many countries around the world. Home mechanical ventilation has been well accepted as a standard treatment of children with chronic respiratory failure. Some children may need mechanical ventilation as a lifelong therapy. To send mechanically ventilated children back home may be more difficult than adults. However, relatively better outcomes have been demonstrated in children. Children could be safely ventilated at home if they are selected and managed properly. Conditions requiring home ventilation include increased respiratory load from airway or lung pathologies, ventilatory muscle weakness and failure of neurologic control of ventilation. Home mechanical ventilation should be considered when the patient develops progressive respiratory failure or intractable failure to wean mechanical ventilation. Polysomnography or overnight pulse oximetry plus capnometry are used to detect nocturnal hypoventilation in early stage of respiratory failure. Ventilator strategy including non-invasive and invasive approach should be individualized for each patient. The author strongly believes that parents and family members are able to take care of their child at home if they are trained and educated effectively. A good team work with dedicated members is the key factor of success.

  13. Ventilation and respiratory mechanics.

    PubMed

    Sheel, Andrew William; Romer, Lee M

    2012-04-01

    During dynamic exercise, the healthy pulmonary system faces several major challenges, including decreases in mixed venous oxygen content and increases in mixed venous carbon dioxide. As such, the ventilatory demand is increased, while the rising cardiac output means that blood will have considerably less time in the pulmonary capillaries to accomplish gas exchange. Blood gas homeostasis must be accomplished by precise regulation of alveolar ventilation via medullary neural networks and sensory reflex mechanisms. It is equally important that cardiovascular and pulmonary system responses to exercise be precisely matched to the increase in metabolic requirements, and that the substantial gas transport needs of both respiratory and locomotor muscles be considered. Our article addresses each of these topics with emphasis on the healthy, young adult exercising in normoxia. We review recent evidence concerning how exercise hyperpnea influences sympathetic vasoconstrictor outflow and the effect this might have on the ability to perform muscular work. We also review sex-based differences in lung mechanics.

  14. Early Mobilization of Mechanically Ventilated Patients.

    PubMed

    Hruska, Pam

    2016-12-01

    Critically ill patients requiring mechanical ventilation are least likely to be mobilized and, as a result, are at-risk for prolonged complications from weakness. The use of bed rest and sedation when caring for mechanically ventilated patients is likely shaped by historical practice; however, this review demonstrates early mobilization, with little to no sedation, is possible and safe. Assessing readiness for mobilization in context of progressing patients from passive to active activities can lead to long-term benefits and has been achievable with resource-efficient implementations and team work.

  15. 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.

  16. 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

  17. Difficult weaning from mechanical ventilation.

    PubMed

    Oh, T E

    1994-07-01

    Weaning from mechanical ventilation may be influenced by factors relating to equipment, techniques and procedures. Criteria to initiate weaning and predictors of weaning outcome are generally unreliable, but mechanical work of breathing, the tidal volume: frequency ratio and the inspiratory pressure: maximal inspiratory pressure ratio may anticipate those likely to fail weaning. The optimal weaning ventilatory mode is not known, but intermittent mandatory ventilation, pressure support ventilation, and continuous positive pressure ventilation are the most commonly used. The resistances of individual components of breathing circuits are extremely important. Blow-by heated humidifiers and ventilators which compensate for the impedances of their inspiratory demand valves impose clinically acceptable spontaneous breathing loads. Close monitoring, adequate respiratory muscle rest, attention to mineral deficiencies, nutrition and pulmonary hygiene are also important parts of the weaning process.

  18. Basic concepts in mechanical ventilation.

    PubMed

    Carbery, Catherine

    2008-03-01

    Mechanical ventilatory support is a major component of the clinical management of critically ill patients admitted into intensive care. Closely linked with the developments within critical care medicine, the use of ventilatory support has been increasing since the polio epidemics in the 1950s (Lassen 1953). Initially used to provide controlled mandatory ventilation, today with advances in technology, most mechanical ventilators are triggered by the patient, increasing the awareness of the complexity of patient/ventilator interaction (Tobin 1994). Though ventilator appearance and design may have changed quite significantly and the variety of options for support extensive, the basic concepts of mechanical ventilatory support of the critically ill patient remains unchanged. This paper aims to outline these concepts so as to gain a better understanding of mechanical ventilatory support.

  19. Early intervention of patients at risk for acute respiratory failure and prolonged mechanical ventilation with a checklist aimed at the prevention of organ failure: protocol for a pragmatic stepped-wedged cluster trial of PROOFCheck.

    PubMed

    Gong, M N; Schenk, L; Gajic, O; Mirhaji, P; Sloan, J; Dong, Y; Festic, E; Herasevich, V

    2016-06-10

    Acute respiratory failure (ARF) often presents and progresses outside of the intensive care unit. However, recognition and treatment of acute critical illness is often delayed with inconsistent adherence to evidence-based care known to decrease the duration of mechanical ventilation (MV) and complications of critical illness. The goal of this trial is to determine whether the implementation of an electronic medical record-based early alert for progressive respiratory failure coupled with a checklist to promote early compliance to best practice in respiratory failure can improve the outcomes of patients at risk for prolonged respiratory failure and death. A pragmatic stepped-wedged cluster clinical trial involving 6 hospitals is planned. The study will include adult hospitalised patients identified as high risk for MV >48 hours or death because they were mechanically ventilated outside of the operating room or they were identified as high risk for ARF on the Accurate Prediction of PROlonged VEntilation (APPROVE) score. Patients with advanced directives limiting intubation will be excluded. The intervention will consist of (1) automated identification and notification of clinician of high-risk patients by APPROVE or by invasive MV and (2) checklist of evidence-based practices in ARF (Prevention of Organ Failure Checklist-PROOFCheck). APPROVE and PROOFCheck will be developed in the pretrial period. Primary outcome is hospital mortality. Secondary outcomes include length of stay, ventilator and organ failure-free days and 6-month and 12-month mortality. Predefined subgroup analysis of patients with limitation of aggressive care after study entry is planned. Generalised estimating equations will be used to compare patients in the intervention phase with the control phase, adjusting for clustering within hospitals and time. The study was approved by the institutional review boards. Results will be published in peer-reviewed journals and presented at international

  20. Mechanical ventilation in the home.

    PubMed

    Make, B J; Gilmartin, M E

    1990-07-01

    Despite advances in the application of mechanical ventilation as a short-term, life-saving technique, intensive care units are increasingly faced with patients who cannot be weaned from ventilatory assistance and who require mechanical ventilation as a long-term, life-supporting necessity. Because of limited resources in health care facilities for the management of chronic ventilator-assisted individuals, home care has become an important option. With careful selection of appropriate candidates, home care for ventilator-assisted individuals can result in not only decreased respiratory symptoms, reduction in hospitalization, and improved physiologic measures, but also an improved quality of life with substantial survival and a reduction in the costs of medical care.

  1. Anxiety and Agitation in Mechanically Ventilated Patients

    PubMed Central

    Tate, Judith Ann; Dabbs, Annette Devito; Hoffman, Leslie; Milbrandt, Eric; Happ, Mary Beth

    2013-01-01

    During an ethnography conducted in an intensive care unit (ICU), we found that anxiety and agitation occurred frequently, and were important considerations in the care of 30 patients weaning from prolonged mechanical ventilation. We conducted a secondary analysis to (a) describe characteristics of anxiety and agitation experienced by mechanically ventilated patients; (b) explore how clinicians recognize and interpret anxiety and agitation and (c) describe strategies and interventions used to manage anxiety and agitation with mechanically ventilated patients. We constructed the Anxiety-Agitation in Mechanical Ventilation Model to illustrate the multidimensional features of symptom recognition and management. Patients’ ability to interact with the environment served as a basis for identification and management of anxiety or agitation. Clinicians’ attributions about anxiety or agitation and “knowing the patient” contributed to their assessment of patient responses. Clinicians chose strategies to overcome either the stimulus or patient’s appraisal of risk of the stimulus. This article contributes to the body of knowledge about symptom recognition and management in the ICU by providing a comprehensive model to guide future research and practice. PMID:21908706

  2. [Nasopharyngeal myiasis during mechanical ventilation].

    PubMed

    Yoshitomi, A; Sato, A; Suda, T; Chida, K

    1997-12-01

    We report a case of myiasis caused by Phaenicia sericata during mechanical ventilation. An 86-year-old woman with bronchiectasis was admitted to our hospital with severe respiratory failure. Treatment with mechanical ventilation and sedatives was initiated. On the 10th day of hospitalization, about 20 white larvae were found in the patient's oral or nasal cavities. The larvae were removed and identified as Phaenicia sericata. No mucosal injury was found in the patient's oral or nasal cavity by endoscopic examination. The patient died of multiple organ failure caused by sepsis that had no association with myiasis. From the clinical course and the fly's life cycle, it is considered that the fly laid eggs in the patient's oral or nasal cavity while she was sedated during mechanical ventilation. Myiasis can occur even in a hospital.

  3. Argon and xenon ventilation during prolonged ex vivo lung perfusion.

    PubMed

    Martens, An; Montoli, Matteo; Faggi, Giulio; Katz, Ira; Pype, Jan; Vanaudenaerde, Bart M; Van Raemdonck, Dirk E M; Neyrinck, Arne P

    2016-03-01

    Evidence supports the use of ex vivo lung perfusion (EVLP) as a platform for active reconditioning before transplantation to increase the potential donor pool and to reduce the incidence of primary graft dysfunction. A promising reconditioning strategy is the administration of inhaled noble gases based on their organoprotective effects. Our aim was to validate a porcine warm ischemic lung injury model and investigate postconditioning with argon (Ar) or xenon (Xe) during prolonged EVLP. Domestic pigs were divided in four groups (n = 5 per group). In the negative control group, lungs were flushed immediately. In the positive control (PC) and treatment (Ar, Xe) groups, lungs were flushed after a warm ischemic interval of 2-h in situ. All grafts were evaluated and treated during normothermic EVLP for 6 h. In the control groups, lungs were ventilated with 70% N2/30% O2 and in the treatment groups with 70% Ar/30% O2 or 70% Xe/30% O2, respectively. Outcome parameters were physiological variables (pulmonary vascular resistance, peak airway pressures, and PaO2/FiO2), histology, wet-to-dry weight ratio, bronchoalveolar lavage, and computed tomography scan. A significant difference between negative control and PC for pulmonary vascular resistance, peak airway pressures, PaO2/FiO2, wet-to-dry weight ratio, histology, and computed tomography-imaging was observed. No significant differences between the injury group (PC) and the treatment groups (Ar, Xe) were found. We validated a reproducible prolonged 6-h EVLP model with 2 h of warm ischemia and described the physiological changes over time. In this model, ventilation during EVLP with Ar or Xe administered postinjury did not improve graft function. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. 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.

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

    PubMed

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

    2015-01-01

    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. 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. 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. 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.

  6. 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

  7. Prognosis of mechanically ventilated patients.

    PubMed Central

    Papadakis, M A; Lee, K K; Browner, W S; Kent, D L; Matchar, D B; Kagawa, M K; Hallenbeck, J; Lee, D; Onishi, R; Charles, G

    1993-01-01

    In this Department of Veterans Affairs cooperative study, we examined predictors of in-hospital and 1-year mortality of 612 mechanically ventilated patients from 6 medical intensive care units in a retrospective cohort design. The outcome variable was vital status at hospital discharge and after 1 year. The results showed that 97% of patients were men, the mean age was 63 +/- 11 years (SD), and hospital mortality was 64% (95% confidence interval, 60% to 68%). Within the next year, an additional 38% of hospital survivors died, for a total 1-year mortality of 77% (95% confidence interval, 73% to 80%). Hospital and 1-year mortality, respectively, for patients older than 70 years was 76% and 94%, for those with serum albumin levels below 20 grams per liter it was 92% and 96%, for those with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score greater than 35 it was 91% and 98%, and for patients who were being mechanically ventilated after cardiopulmonary resuscitation it was 86% and 90%. The mortality ratio (actual mortality versus APACHE II-predicted mortality) was 1.15. Conclusions are that patient age, APACHE II score, serum albumin levels, or the use of cardiopulmonary resuscitation may identify a subset of mechanically ventilated veterans for whom mechanical ventilation provides little or no benefit. PMID:8128673

  8. Cardiovascular effects of mechanical ventilation and weaning.

    PubMed

    Frazier, Susan K

    2008-03-01

    Because of their anatomic position in the closed thoracic cavity, the heart and lungs interact during each ventilation cycle. The application of mechanical ventilation and subsequent removal changes normal ventilatory mechanics and produces alterations in cardiac preload and afterload that influence global hemodynamic state and delivery of oxygen and nutrients. Adverse cardiovascular responses to mechanical ventilation and weaning from ventilation include hemodynamic alterations and instability, myocardial ischemia, autonomic dysfunction, and cardiac dysrhythmias. Clinicians must have a clear understanding of the cardiovascular effects of mechanical ventilation and weaning so they may anticipate, recognize, and effectively manage negative effects and improve patient outcomes.

  9. Economics of mechanical ventilation and respiratory failure.

    PubMed

    Cooke, Colin R

    2012-01-01

    For patients with acute respiratory failure, mechanical ventilation provides the most definitive life-sustaining therapy. Because of the intense resources required to care for these patients, its use accounts for considerable costs. There is great societal need to ensure that use of mechanical ventilation maximizes societal benefits while minimizing costs, and that mechanical ventilation, and ventilator support in general, is delivered in the most efficient and cost-effective manner. This review summarizes the economic aspects of mechanical ventilation and summarizes the existing literature that examines its economic impact cost effectiveness.

  10. 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

  11. [Mechanical ventilation during thoracic anesthesia].

    PubMed

    Valenza, F

    1999-05-01

    Aim of the study was to test individual mechanical and functional responses to open chest lateral decubitus during one lung ventilation. We measured dependent lung pressure volume (P-V) curves of 19 patients during supine and lateral decubitus. We found that patients characterized by high FEV1 developed greater changes in P-V curve shape than those characterized by low FEV1. Based on these results we decided to test a ventilation strategy characterized by the use of ZEEP or PEEP = 10 cm H2O applied to the dependent lung. In a preliminary set of patients stratified by FEV1 we found that PEEP deteriorated PaO2/FiO2 in patients with low FEV1, while there was a trend towards improvement in patients with high FEV1. It is possible that dependent lung PEEP counteracts atelectasias in normal lungs, while it may divert blood flow or create dead space in patients with sick and stiff lungs. We conclude that during one lung ventilation in open chest lateral decubitus, ventilatory setting need to be individually tailored.

  12. 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.

  13. Estimating Respiratory Mechanical Parameters during Mechanical Ventilation

    PubMed Central

    Barbini, Paolo

    1982-01-01

    We propose an algorithm for the estimation of the parameters of the mechanical respiratory system. The algorithm is based on non linear regression analysis with a two-compartment respiratory system model. The model used allows us to take account of the non homogeneous properties of the lungs which may cause uneven distribution of ventilation and thus affect the gas exchange in the lungs. The estimation of the parameters of such a model permits the optimization of the type of ventilation to be used in patients undergoing respiratory treatment. This can be done bearing in mind the effects of the mechanical ventilation on venous return as well as the quality of gas exchange. We have valued the performances of the estimation algorithm which is proposed on the basis of the agreement between the data and the model response, of the stability of the parameter estimates and of the standard deviations of the parameters. The parameter estimation algorithm described does not have recourse to the examination of the impedance spectra and is completely independent of the type of ventilator employed.

  14. 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.

  15. Assisted mechanical ventilation: the future is now!

    PubMed

    Kacmarek, Robert M; Pirrone, Massimiliano; Berra, Lorenzo

    2015-07-29

    Assisted ventilation is a highly complex process that requires an intimate interaction between the ventilator and the patient. The complexity of this form of ventilation is frequently underappreciated by the bedside clinician. In assisted mechanical ventilation, regardless of the specific mode, the ventilator's gas delivery pattern and the patient's breathing pattern must match near perfectly or asynchrony between the patient and the ventilator occurs. Asynchrony can be categorized into four general types: flow asynchrony; trigger asynchrony; cycle asynchrony; and mode asynchrony. In an article recently published in BMC Anesthesiology, Hodane et al. have demonstrated reduced asynchrony during assisted ventilation with Neurally Adjusted Ventilatory Assist (NAVA) as compared to pressure support ventilation (PSV). These findings add to the growing volume of data indicating that modes of ventilation that provide proportional assistance to ventilation - e.g., NAVA and Proportional Assist Ventilation (PAV) - markedly reduce asynchrony. As it becomes more accepted that the respiratory center of the patient in most circumstances is the most appropriate determinant of ventilatory pattern and as the negative outcome effects of patient-ventilator asynchrony become ever more recognized, we can expect NAVA and PAV to become the preferred modes of assisted ventilation!

  16. Outcomes and predictors of prolonged ventilation in patients undergoing elective coronary surgery†

    PubMed Central

    Saleh, Hesham Z.; Shaw, Matthew; Al-Rawi, Omar; Yates, Jonathan; Pullan, D. Mark; Chalmers, John A.C.; Fabri, Brian M.

    2012-01-01

    OBJECTIVES Despite the seriousness of prolonged mechanical ventilation (PMV) as a postoperative complication, previously proposed risk prediction models were met with limited success. The purpose of this study was to identify perioperative variables associated with PMV in elective primary coronary bypass surgery. PMV was defined as the need for intubation and mechanical ventilation for >72 h, after completion of the operation. METHODS Between April 1997 and September 2010, 10 977 consecutive patients were retrospectively reviewed. A series of two multivariate logistic regression analyses were carried out to identify preoperative predictors of prolonged ventilation and the impact of operative variables. RESULTS PMV occurred in 215 (1.96%) patients; 119 (55.3%) of these underwent tracheostomy. At multivariate analysis, predictors included NYHA higher than class II (odds ratio [OR], 1.77; 95% confidence intervals [CI], 1.34–2.34), renal dialysis (OR, 5.5; 95% CI, 2.08–14.65), age at operation (OR, 1.04; 95% CI, 1.02–1.06), reduced FEV1 (OR, 0.99; 95% CI, 0.98–0.99), body mass index >35 kg/m2 (OR, 1.73; 95% CI, 1.14–2.63). On serial logistic regression analyses, operative variables added little to the discriminatory power of the model. Kaplan–Meier survival curves showed reduced survival among PMV patients (P < 0.001) with an improved survival in the tracheostomy subgroup. CONCLUSIONS PMV after coronary bypass is associated with a reduction in early and mid-term survival. Risk modelling for PMV remains problematic even when examining a more homogenous lower risk group. PMID:22495507

  17. Mechanical ventilation reduces rat diaphragm blood flow and impairs oxygen delivery and uptake.

    PubMed

    Davis, Robert T; Bruells, Christian S; Stabley, John N; McCullough, Danielle J; Powers, Scott K; Behnke, Bradley J

    2012-10-01

    Although mechanical ventilation is a life-saving intervention in patients suffering from respiratory failure, prolonged mechanical ventilation is often associated with numerous complications including problematic weaning. In contracting skeletal muscle, inadequate oxygen supply can limit oxidative phosphorylation resulting in muscular fatigue. However, whether prolonged mechanical ventilation results in decreased diaphragmatic blood flow and induces an oxygen supply-demand imbalance in the diaphragm remains unknown. We tested the hypothesis that prolonged controlled mechanical ventilation results in a time-dependent reduction in rat diaphragmatic blood flow and microvascular PO2 and that prolonged mechanical ventilation would diminish the diaphragm's ability to increase blood flow in response to muscular contractions. Compared to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation resulted in a 75% reduction in diaphragm blood flow (via radiolabeled microspheres), which did not occur in the intercostal muscle or high-oxidative hindlimb muscle (e.g., soleus). There was also a time-dependent decline in diaphragm microvascular PO2 (via phosphorescence quenching). Further, contrary to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation significantly compromised the diaphragm's ability to increase blood flow during electrically-induced contractions, which resulted in a ~80% reduction in diaphragm oxygen uptake. In contrast, 6 hrs of spontaneous breathing in anesthetized animals did not alter diaphragm blood flow or the ability to augment flow during electrically-induced contractions. These new and important findings reveal that prolonged mechanical ventilation results in a time-dependent decrease in the ability of the diaphragm to augment blood flow to match oxygen demand in response to contractile activity and could be a key contributing factor to difficult weaning. Although additional experiments are required to confirm, it is tempting to

  18. 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%.

  19. The effects of prolonged inspiratory time during one-lung ventilation: a randomised controlled trial.

    PubMed

    Lee, S M; Kim, W H; Ahn, H J; Kim, J A; Yang, M K; Lee, C H; Lee, J H; Kim, Y R; Choi, J W

    2013-09-01

    We evaluated the effects of a prolonged inspiratory time on gas exchange in subjects undergoing one-lung ventilation for thoracic surgery. One hundred patients were randomly assigned to Group I:E = 1:2 or Group I:E = 1:1. Arterial blood gas analysis and respiratory mechanics measurements were performed 10 min after anaesthesia induction, 30 and 60 min after initiation of one-lung ventilation, and 15 min after restoration of conventional two-lung ventilation. The mean (SD) ratio of the partial pressure of arterial oxygen to fraction of inspired oxygen after 60 min of one-lung ventilation was significantly lower in Group I:E = 1:2 compared with Group I:E = 1:1 (27.7 (13.2) kPa vs 35.2 (22.1) kPa, respectively, p = 0.043). Mean (SD) physiological dead space-to-tidal volume ratio after 60 min of one-lung ventilation was significantly higher in Group I:E = 1:2 compared with Group I:E = 1:1 (0.46 (0.04) vs 0.43 (0.04), respectively, p = 0.008). Median (IQR [range]) peak inspiratory pressure was higher in Group I:E = 1:2 compared with Group I:E = 1:1 after 60 min of one-lung ventilation (23 (22-25 [18-29]) cmH2O vs 20 (18-21 [16-27]) cmH2O, respectively, p < 0.001) and median (IQR [range]) mean airway pressure was lower in Group I:E = 1:2 compared with Group I:E = 1:1 (10 (8-11 [5-15]) cmH2O vs 11 (10-13 [5-16]) cmH2O, respectively, p < 0.001). We conclude that, compared with an I:E ratio of 1:2, an I:E ratio of 1:1 resulted in a modest improvement in oxygenation and decreased shunt fraction during one-lung ventilation.

  20. Mechanical ventilation: what have we learned?

    PubMed

    Fenstermacher, Denise; Hong, Dennis

    2004-01-01

    Mechanical ventilation is the second most frequently performed therapeutic intervention after treatment for cardiac arrhythmias in intensive care units today. Countless lives have been saved with its use despite being associated with a greater than 30% in-hospital mortality rate. As life expectancies increase and people with chronic illnesses survive longer, artificial support with mechanical ventilation is also expected to rise. In one survey, over half of senior internal medicine residents reported their training on mechanical ventilation as inadequate, whereas the majority of critical care nurses reported having received no formal education on its use. Technological advances resulting in the availability of sleeker ventilators with graphic waveform displays and new modes of ventilation have challenged the bedside clinicians to incorporate this new data along with evidenced-based research into their daily practice. A review of current thoughts on mechanical ventilation and weaning is presented.

  1. [VENTILOP survey. Survey in peroperative mechanical ventilation].

    PubMed

    Fischer, F; Collange, O; Mahoudeau, G; Simon, M; Moussa, H; Thibaud, A; Steib, A; Pottecher, T; Mertes, M

    2014-06-01

    Mechanical ventilation can initiate ventilator-associated lung injury and postoperative pulmonary complications. The aim of this study was to evaluate (1) how mechanical ventilation was comprehended by anaesthetists (physician and nurses) and (2) the need for educational programs. A computing questionnary was sent by electronic-mail to the entire anaesthetist from Alsace region in France (297 physicians), and to a pool of 99 nurse anaesthetists. Mechanical ventilation during anaesthesia was considered as optimized when low tidal volume (6-8mL) of ideal body weight was associated with positive end expiratory pressure, FiO2 less than 50%, I/E adjustment and recruitment maneuvers. The participation rate was 50.5% (172 professionals). Only 2.3% of professionals used the five parameters for optimized ventilation. Majority of professionals considered that mechanical ventilation adjustment influenced the patients' postoperative outcome. Majority of the professionals asked for a specific educational program in the field of mechanical ventilation. Only 2.3% of professionals optimized mechanical ventilation during anaesthesia. Guidelines and specific educational programs in the field of mechanical ventilation are widely expected. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

  2. Tracheomegaly and tracheosephagial fistula following mechanical ventilation: A case report and review of the literature

    PubMed Central

    Kucuk, Canan; Arda, Kemal; Ata, Naim; Turkkani, Mustafa Hamidullah; Yildiz, Özgür Ömer

    2016-01-01

    Postintubation Tracheoesophageal fistula (TEF) is a rare complication. Acquired TEF most commonly occurred following prolonged mechanical ventilation with an endotracheal or tracheostomy tube, cuff-related tracheal injury, post-intubation injury. We present a case of both tracheomegaly and tracheosephagial fistula following mechanical ventilation for 15 days, in the light of the literature. PMID:27222792

  3. [Prevalence of mechanical ventilation in pediatric intensive care units in Spain].

    PubMed

    Balcells Ramírez, J; López-Herce Cid, J; Modesto Alapont, V

    2004-12-01

    To study the prevalence and characteristics of mechanical ventilation in children admitted to Spanish pediatric intensive care units (PICU). A prospective, multicenter, observational study was performed using a written questionnaire sent to the 46 PICUs in Spain. Clinical data and mechanical ventilation settings in patients undergoing mechanical ventilation on 19th February 2002 were collected. Thirty-three PICUs participated in the study (27 had patients undergoing mechanical ventilation on the study day). The prevalence of mechanical ventilation was 86 patients (45.5 %). The mean age of patients undergoing mechanical ventilation was 36 months and the median was 8 months. Sixty percent of the patients were boys. The main indications for mechanical ventilation were acute respiratory failure (46.5 %), chronic respiratory failure (10.4 %), coma (11.6 %) and postoperative status (10.5 %). Endotracheal tubes were used in 73.2 % and a tracheostomy tube was used in 23.2 %. The most frequent mechanical ventilation modalities used were synchronized intermittent mandatory ventilation (SIMV) in 43 % and control or assisted-control ventilation in 36 %. In 30 % of the patients the duration of mechanical ventilation was longer than 1 month. From the initiation of mechanical ventilation to the study day, pneumothorax developed in 8.1 % of the patients, accidental extubation occurred in 10.5 % and ventilator-associated pneumonia developed in 17.4 %. A high percentage of children admitted to the PICU requires mechanical ventilation. The most frequent indication is respiratory failure. The most frequently used modality in children aged less than 1 month is pressure SIMV. In children older than 1 month volume-cycled or pressure-limited ventilation and volume-cycled SMIV are used in similar proportions. The prevalence of prolonged mechanical ventilation and the incidence of ventilator-associated complications are very high.

  4. Mitochondria-targeted antioxidants protect against mechanical ventilation-induced diaphragm weakness.

    PubMed

    Powers, Scott K; Hudson, Matthew B; Nelson, W Bradley; Talbert, Erin E; Min, Kisuk; Szeto, Hazel H; Kavazis, Andreas N; Smuder, Ashley J

    2011-07-01

    Mechanical ventilation is a life-saving intervention used to provide adequate pulmonary ventilation in patients suffering from respiratory failure. However, prolonged mechanical ventilation is associated with significant diaphragmatic weakness resulting from both myofiber atrophy and contractile dysfunction. Although several signaling pathways contribute to diaphragm weakness during mechanical ventilation, it is established that oxidative stress is required for diaphragmatic weakness to occur. Therefore, identifying the site(s) of mechanical ventilation- induced reactive oxygen species production in the diaphragm is important. These experiments tested the hypothesis that elevated mitochondrial reactive oxygen species emission is required for mechanical ventilation-induced oxidative stress, atrophy, and contractile dysfunction in the diaphragm. Cause and effect was determined by preventing mechanical ventilation-induced mitochondrial reactive oxygen species emission in the diaphragm of rats using a novel mitochondria-targeted antioxidant (SS-31). None. Compared to mechanically ventilated animals treated with saline, animals treated with SS-31 were protected against mechanical ventilation-induced mitochondrial dysfunction, oxidative stress, and protease activation in the diaphragm. Importantly, treatment of animals with the mitochondrial antioxidant also protected the diaphragm against mechanical ventilation-induced myofiber atrophy and contractile dysfunction. These results reveal that prevention of mechanical ventilation-induced increases in diaphragmatic mitochondrial reactive oxygen species emission protects the diaphragm from mechanical ventilation-induced diaphragmatic weakness. This important new finding indicates that mitochondria are a primary source of reactive oxygen species production in the diaphragm during prolonged mechanical ventilation. These results could lead to the development of a therapeutic intervention to impede mechanical ventilation

  5. 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.

  6. Factors associated with prolonged ventilation and reintubation in adult spinal deformity surgery.

    PubMed

    De la Garza Ramos, Rafael; Nakhla, Jonathan; Nasser, Rani; Jada, Ajit; Purvis, Taylor E; Sciubba, Daniel M; Kinon, Merrit; Yassari, Reza

    2017-09-01

    Prolonged ventilation or reintubation are severe complications after scoliosis surgery, but there is limited data regarding their incidence and risk factors. The purpose of this study is to investigate the incidence and risk factors for prolonged ventilation and reintubation in adult spinal deformity (ASD) surgery. The American College of Surgeons National Surgical Quality Improvement Program database (2007-2013) was reviewed. Inclusion criteria were adult patients over 21years of age who underwent spinal fusion for ASD. The association between patient/operative characteristics and prolonged ventilation/reintubation was investigated via multivariate analysis. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). There were 1250 patients who underwent ASD surgery and met our inclusion criteria. Among these, there were 34 patients who required prolonged ventilation (2.7%) and 22 patients who underwent reintubation (1.8%). Factors associated with prolonged ventilation after multivariate analysis were history of bleeding disorder (OR 5.67; 95% CI, 1.01-31.83) and operative time over 6h (OR 3.72; 95% CI, 1.17-11.80). For reintubation, these included older age (OR 1.06; 95% CI, 1.01-1.12), history of bleeding disorder (OR 12.21; 95% CI, 2.03-73.42), and fusion of 13 or more spinal levels (OR 9.14; 95% CI, 1.53-54.63). In conclusion, prolonged ventilation and reintubation in ASD surgery are uncommon events. Older patients, patients with bleeding disorders, and those undergoing long operations and fusion of 13 more spinal segments may be at an increased risk for these occurrences. Copyright © 2017 Elsevier Ltd. All rights reserved.

  7. 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

  8. Tracheostomy tube enabling speech during mechanical ventilation.

    PubMed

    Nomori, Hiroaki

    2004-03-01

    A voice tracheostomy tube (VTT) was developed to enable patients to speak during mechanical ventilation. The VTT has slits cut in it and is covered on part of its side with an elastic cuff, enabling the cuff to expand with positive pressure from the ventilator on inspiration and to deflate on expiration. By this mechanism, inspired air from the ventilator goes to the lung with the cuff inflated, and some of the expired air passes out around the deflated cuff and discharges through the glottis, allowing sufficient ventilation and also enabling vocal fold vibration. An experiment using a model lung showed that there was little leakage on inspiration even for low lung compliance and high airway pressure, and that the leakage volume on expiration was approximately 40% of the ventilated volume, ie, the volume discharging through the vocal fold in clinical use. Sixteen patients who had been managed by ventilation via a conventional tracheostomy tube were switched to the VTT. All patients except one were able to speak after switching to the VTT without change in PaO(2) and PaCO(2). There were no complications associated with the use of the VTT. Bronchoscopy showed that the cuff of the VTT did not damage the tracheal mucosa. The VTT enables patients to speak during mechanical ventilation with sufficient ventilation and without aspiration and damage to the tracheal mucosa, even in patients with low lung compliance.

  9. 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

  10. 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.

  11. Respiratory dynamics and dead space to tidal volume ratio of volume-controlled versus pressure-controlled ventilation during prolonged gynecological laparoscopic surgery.

    PubMed

    Lian, Ming; Zhao, Xiao; Wang, Hong; Chen, Lianhua; Li, Shitong

    2016-12-30

    Laparoscopic operations have become longer and more complex and applied to a broader patient population in the last decades. Prolonged gynecological laparoscopic surgeries require prolonged pneumoperitoneum and Trendelenburg position, which can influence respiratory dynamics and other measurements of pulmonary function. We investigated the differences between volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) and tried to determine the more efficient ventilation mode during prolonged pneumoperitoneum in gynecological laparoscopy. Twenty-six patients scheduled for laparoscopic radical hysterectomy combined with or without laparoscopic pelvic lymphadenectomy were randomly allocated to be ventilated by either VCV or PCV. Standard anesthesic management and laparoscopic procedures were performed. Measurements of respiratory and hemodynamic dynamics were obtained after induction of anesthesia, at 10, 30, 60, and 120 min after establishing pneumoperitoneum, and at 10 min after return to supine lithotomy position and removal of carbon dioxide. The logistic regression model was applied to predict the corresponding critical value of duration of pneumoperitoneum when the Ppeak was higher than 40 cmH2O. Prolonged pneumoperitoneum and Trendelenburg position produced significant and clinically relevant changes in dynamic compliance and respiratory mechanics in anesthetized patients under PCV and VCV ventilation. Patients under PCV ventilation had a similar increase of dead space/tidal volume ratio, but had a lower Ppeak increase compared with those under VCV ventilation. The critical value of duration of pneumoperitoneum was predicted to be 355 min under VCV ventilation, corresponding to the risk of Ppeak higher than 40 cmH2O. Both VCV and PCV can be safely applied to prolonged gynecological laparoscopic surgery. However, PCV may become the better choice of ventilation after ruling out of other reasons for Ppeak increasing.

  12. [Physiotherapy on the mechanically ventilated patients].

    PubMed

    Jerre, George; Beraldo, Marcelo A; Silva, Thelso de Jesus; Gastaldi, Ada; Kondo, Claudia; Leme, Fábia; Guimarães, Fernando; Forti Junior, Germano; Lucato, Jeanette J J; Veja, Joaquim M; Luque, Alexandre; Tucci, Mauro R; Okamoto, Valdelis N

    2007-09-01

    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. Physical therapy during mechanical ventilation has been one of the updated topics. This objective was described the most important topics on the physical therapy during mechanical ventilation. Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words: mechanical ventilation and physical therapy. Recommendations on the most important techniques applied during mechanical ventilation. Physical therapy has a central role at the Intensive Care environment, mainly in patients submitted to a mechanical ventilatory support invasive or non invasive.

  13. 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.

  14. 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

  15. Risk factors associated with increased length of mechanical ventilation in children.

    PubMed

    Payen, Valérie; Jouvet, Philippe; Lacroix, Jacques; Ducruet, Thierry; Gauvin, France

    2012-03-01

    Invasive mechanical ventilation, if prolonged, may lead to high morbidity and mortality. To determine the incidence rate and early risk factors for prolonged acute invasive mechanical ventilation in children. Retrospective longitudinal cohort study over a 1-yr period. All consecutive episodes of invasive mechanical ventilation in the pediatric intensive care units of Sainte-Justine Hospital (Montreal, Canada) were included. Risk factors for long (≥96 hrs) vs. short (<96 hrs) duration of ventilation were determined by logistic regression. None. Among the 360 episodes of invasive ventilation, 36% had a length of ≥96 hrs. Following multivariate analysis, significant risk factors for prolonged acute invasive mechanical ventilation were age of <12 months (odds ratio 3.27, 95% confidence interval 1.90-5.63), Pediatric Risk of Mortality score of ≥15 at admission (odds ratio 3.41, 95% confidence interval 1.31-8.89), mean airway pressure of ≥13 cm H(2)O on day 1 (odds ratio 5.92, 95% confidence interval 3.08-11.36), use of continuous intravenous sedation on day 1 (odds ratio 1.75, 95% confidence interval 1.00-3.05), and use of noninvasive ventilation before intubation (odds ratio 6.56, 95% confidence interval 1.99-21.63). Among the risk factors identified, the use of noninvasive ventilation and continuous intravenous sedation on the first day of ventilation are the only two interventions that were associated with prolonged acute invasive mechanical ventilation. Further research is needed to study the impact of sedation protocols on the duration of mechanical ventilation in children.

  16. Electrical Impedance Tomography During Mechanical Ventilation.

    PubMed

    Walsh, Brian K; Smallwood, Craig D

    2016-10-01

    Electrical impedance tomography (EIT) is a noninvasive, non-radiologic imaging modality that may be useful for the quantification of lung disorders and titration of mechanical ventilation. The principle of operation is based on changes in electrical conductivity that occur as a function of changes in lung volume during ventilation. EIT offers potentially important benefits over standard imaging modalities because the system is portable and non-radiologic and can be applied to patients for long periods of time. Rather than providing a technical dissection of the methods utilized to gather, compile, reconstruct, and display EIT images, the present article seeks to provide an overview of the clinical application of this technology as it relates to monitoring mechanical ventilation and providing decision support at the bedside. EIT has been shown to be useful in the detection of pneumothoraces, quantification of pulmonary edema and comparison of distribution of ventilation between different modes of ventilation and may offer superior individual titration of PEEP and other ventilator parameters compared with existing approaches. Although application of EIT is still primarily done within a research context, it may prove to be a useful bedside tool in the future. However, head-to-head comparisons with existing methods of mechanical ventilation titration in humans need to be conducted before its application in general ICUs can be recommended. Copyright © 2016 by Daedalus Enterprises.

  17. Analysis of respiratory mechanics during artificial ventilation.

    PubMed

    Guttmann, J

    1998-04-01

    Mechanical or artificial ventilation is the most important life-saving therapeutic instrument in modern intensive care medicine. The ventilator takes on the convective transport of the respiratory gas, i.e. delivery of oxygen and removal of carbon dioxide. The technical gas delivery system (ventilator, respiratory tubing system, gas humidifier) and the respiratory system (lungs and thorax) of the patients form a connected pneumatic system of high complexity. The respiratory system produces a mechanical impedance to ventilator output. Impedance is composed of an elastic, a non-elastic, i.e. resistive, and an inertive part. The corresponding indices describing respiratory mechanics are compliance, flow resistance and inertance. Based on the equation of motion of the respiratory system, several methods of analysing respiratory mechanics during mechanical ventilation are described. Quantitative analysis of respiratory system mechanics (a) is a prerequisite for the understanding of the complex patient-ventilator interaction, (b) provides important clinical information on pulmonary function and the course of disease, and (c) allows the physician at the bedside to adjust the ventilatory settings to the needs of the individual patient.

  18. [Mechanical ventilation at home: facts and questions].

    PubMed

    Fitting, J W

    1993-06-15

    Treatment of respiratory insufficiency with retention of CO2 by mechanic ventilation has come into use over the last decade, favored by use of non-invasive methods like nasal ventilation. Best results have been observed in hypercapnic respiratory insufficiency caused by neuromuscular disease or restrictive pathologic changes of the lung. Nocturnal use of nasal ventilation alone is often sufficient to correct also the daily CO2-values. Mechanisms explaining this beneficial effect are not yet known-The respiratory CNS-centers, respiratory muscles or thoracopulmonary mechanics may play etiologically an important role. Medical indications for nasal ventilation in chronic obstructive pulmonary disease are not clear, since results from several studies are controversial. Also in severe or progressive neurologic diseases a critical evaluation is mandatory for assessment of benefits including improvement of quality of life.

  19. Mechanical ventilation and respiratory mechanics during equine anesthesia.

    PubMed

    Moens, Yves

    2013-04-01

    The mechanical ventilation of horses during anesthesia remains a crucial option for optimal anesthetic management, if the possible negative cardiovascular side effects are managed, because this species is prone to hypercapnia and hypoxemia. The combined use of capnography and pitot-based spirometry provide complementary information on ventilation and respiratory mechanics, respectively. This facilitates management of mechanical ventilation in conditions of changing respiratory system compliance (ie, laparoscopy) and when investigating new ventilatory strategies including alveolar recruitment maneuvers and optimization of positive expiratory pressure.

  20. 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.

  1. 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.

  2. 46 CFR 154.1200 - Mechanical ventilation system: General.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 46 Shipping 5 2014-10-01 2014-10-01 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...

  3. 46 CFR 154.1205 - Mechanical ventilation system: Standards.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 46 Shipping 5 2014-10-01 2014-10-01 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...

  4. 46 CFR 154.1200 - Mechanical ventilation system: General.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 46 Shipping 5 2013-10-01 2013-10-01 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...

  5. 46 CFR 154.1205 - Mechanical ventilation system: Standards.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 46 Shipping 5 2013-10-01 2013-10-01 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...

  6. 46 CFR 154.1205 - Mechanical ventilation system: Standards.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 46 Shipping 5 2011-10-01 2011-10-01 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...

  7. 46 CFR 154.1200 - Mechanical ventilation system: General.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 46 Shipping 5 2011-10-01 2011-10-01 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...

  8. 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 VT 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 improved

  9. 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

  10. Nuclear factor-κB signaling contributes to mechanical ventilation-induced diaphragm weakness*.

    PubMed

    Smuder, Ashley J; Hudson, Matthew B; Nelson, W Bradley; Kavazis, Andreas N; Powers, Scott K

    2012-03-01

    Although mechanical ventilation is a life-saving measure for patients in respiratory failure, prolonged mechanical ventilation results in diaphragmatic weakness attributable to fiber atrophy and contractile dysfunction. Therefore, identifying the signaling pathways responsible for mechanical ventilation-induced diaphragmatic weakness is important. In this context, it is established that oxidative stress is required for mechanical ventilation-induced diaphragmatic weakness to occur. Numerous redox-sensitive signaling pathways exist in muscle including the transcription factor nuclear factor-κB. Although it has been suggested that nuclear factor-κB contributes to proteolytic signaling in inactivity-induced atrophy in locomotor muscles, the role that nuclear factor-κB plays in mechanical ventilation-induced diaphragmatic weakness is unknown. We tested the hypothesis that nuclear factor-κB activation plays a key signaling role in mechanical ventilation-induced diaphragmatic weakness and that oxidative stress is required for nuclear factor-κB activation. Cause and effect was determined by independently treating mechanically ventilated animals with either a specific nuclear factor-κB inhibitor (SN50) or a clinically relevant antioxidant (curcumin). Inhibition of nuclear factor-κB activity partially attenuated both mechanical ventilation-induced diaphragmatic atrophy and contractile dysfunction. Further, treatment with the antioxidant curcumin prevented mechanical ventilation-induced activation of nuclear factor-κB in the diaphragm and rescued the diaphragm from both mechanical ventilation-induced atrophy and contractile dysfunction. Collectively, these findings support the hypothesis that nuclear factor-κB activation plays a significant signaling role in mechanical ventilation-induced diaphragmatic weakness and that oxidative stress is an upstream activator of nuclear factor-κB. Finally, our results suggest that prevention of mechanical ventilation

  11. Intelligent decision support systems for mechanical ventilation.

    PubMed

    Tehrani, Fleur T; Roum, James H

    2008-11-01

    An overview of different methodologies used in various intelligent decision support systems (IDSSs) for mechanical ventilation is provided. The applications of the techniques are compared in view of today's intensive care unit (ICU) requirements. Information available in the literature is utilized to provide a methodological review of different systems. Comparisons are made of different systems developed for specific ventilation modes as well as those intended for use in wider applications. The inputs and the optimized parameters of different systems are discussed and rule-based systems are compared to model-based techniques. The knowledge-based systems used for closed-loop control of weaning from mechanical ventilation are also described. Finally, in view of increasing trend towards automation of mechanical ventilation, the potential utility of intelligent advisory systems for this purpose is discussed. IDSSs for mechanical ventilation can be quite helpful to clinicians in today's ICU settings. To be useful, such systems should be designed to be effective, safe, and easy to use at patient's bedside. In particular, these systems must be capable of noise removal, artifact detection and effective validation of data. Systems that can also be adapted for closed-loop control/weaning of patients at the discretion of the clinician, may have a higher potential for use in the future.

  12. 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

    2017-09-22

    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.

  13. [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.

  14. Home Mechanical Ventilation in South Korea

    PubMed Central

    Kim, Dong Hyun; Choi, Won Ah

    2014-01-01

    Purpose To survey the use of invasive and noninvasive home mechanical ventilation (HMV) methods in South Korea from the perspective of physical medicine and rehabilitation (PM&R). Materials and Methods For 413 users of HMV, retrospective reviews of PM&R interventions and survey of HMV methods employed from Mar 2000 to Dec 2009. Results Of the 413 users, the majority of whom with progressive neuromuscular disorders (NMDs) (n=358), 284 patients initially used noninvasive mechanical ventilation (NIV), while 63 others who were using tracheostomy mechanical ventilation switched to NIV as part of their rehabilitation. The NMD patients began HMV at an earlier age (34.9±20.3 yrs), and used for longer (14.7±7.5) hours than patients with non-neuromuscular causes of respiratory impairment. Conclusion Noninvasive management was preferred over invasive ones, and transition to the former was a result of PM&R interventions. PMID:25323913

  15. Quality of life of ALS and LIS patients with and without invasive mechanical ventilation.

    PubMed

    Rousseau, Marie-Christine; Pietra, Stéphane; Blaya, José; Catala, Anne

    2011-10-01

    There are very few studies where quality of life (QOL) is assessed in patients with complete physical and functional disability and dependence to invasive mechanical ventilation (IV). We compared QOL of amyotrophic lateral sclerosis (ALS) and locked-in-syndrome (LIS) patients with invasive mechanical ventilation to ALS and LIS patients without mechanical invasive ventilation. Thirty-four patients, 27 with ALS and seven with LIS (vascular or tumoral aetiology) were included in the study. Twelve had invasive ventilation, 22 had non-invasive ventilation, and in the non-invasive ventilation group, five of them had ventilation via mask. The following scales were used for patients: ALS Functional Rating Scale (ALSFRS), McGILL, Short-Form 36 (SF36), Beck Depression Inventory-II, the Toronto Alexithymia Scale and the anxiety inventory of Spielberger. Mean ALSFRS scores were significantly lower in the invasive ventilation group (IV) than in the non-invasive ventilation group. McGILL and SF36 were not significantly different between the IV group and the non-invasive ventilation group; there were no significant differences between the two groups for others scales either. Comparison between IV group and LIS without invasive mechanical ventilation revealed no significant difference for SF36 and McGILL QOL scores. QOL was not significantly different between the IV and not invasively ventilated patients, but ALSFRS was significantly lower in the IV group, and comparison of QOL scores between non-ventilated LIS patients who had the same score of dependence that invasively ventilated patients did not show any difference. Invasive mechanical ventilation for patients who accept tracheotomy allows life prolongation and their QOL is not affected; medical teams should be aware of that.

  16. 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.

  17. Mechanical Ventilation in Sepsis: A Reappraisal.

    PubMed

    Zampieri, Fernando G; Mazza, Bruno

    2017-01-01

    Sepsis is the main cause of close to 70% of all cases of acute respiratory distress syndromes (ARDS). In addition, sepsis increases susceptibility to ventilator-induced lung injury. Therefore, the development of a ventilatory strategy that can achieve adequate oxygenation without injuring the lungs is highly sought after for patients with acute infection and represents an important therapeutic window to improve patient care. Suboptimal ventilatory settings cannot only harm the lung, but may also contribute to the cascade of organ failure in sepsis due to organ crosstalk.Despite the prominent role of sepsis as a cause for lung injury, most of the studies that addressed mechanical ventilation strategies in ARDS did not specifically assess sepsis-related ARDS patients. Consequently, most of the recommendations regarding mechanical ventilation in sepsis patients are derived from ARDS trials that included multiple clinical diagnoses. While there have been important improvements in general ventilatory management that should apply to all critically ill patients, sepsis-related lung injury might still have particularities that could influence bedside management.After revisiting the interplay between sepsis and ventilation-induced lung injury, this review will reappraise the evidence for the major components of the lung protective ventilation strategy, emphasizing the particularities of sepsis-related acute lung injury.

  18. 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)

  19. 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)

  20. Special cases: mechanical ventilation of neurosurgical patients.

    PubMed

    Johnson, Victoria E; Huang, Jason H; Pilcher, Webster H

    2007-04-01

    Mechanical ventilation has evolved greatly over the last half century, guided primarily by improved comprehension of the relevant pathology/physiology. Neurosurgical patients are a unique subgroup of patients who heavily use this technology for both support, and less commonly, as a therapy. Such patients demand special consideration with regard to mode of ventilation, use of positive end-expiratory pressure, and monitoring. In addition, meeting the ventilatory needs of neurosurgical patients while minimizing ventilatory-induced lung damage can be a challenging aspect of care.

  1. Assessment of mechanical ventilation parameters on respiratory mechanics.

    PubMed

    Pidaparti, Ramana M; Koombua, Kittisak; Ward, Kevin R

    2012-01-01

    Better understanding of airway mechanics is very important in order to avoid lung injuries for patients undergoing mechanical ventilation for treatment of respiratory problems in intensive-care medicine, as well as pulmonary medicine. Mechanical ventilation depends on several parameters, all of which affect the patient outcome. As there are no systematic numerical investigations of the role of mechanical ventilation parameters on airway mechanics, the objective of this study was to investigate the role of mechanical ventilation parameters on airway mechanics using coupled fluid-solid computational analysis. For the airway geometry of 3 to 5 generations considered, the simulation results showed that airflow velocity increased with increasing airflow rate. Airway pressure increased with increasing airflow rate, tidal volume and positive end-expiratory pressure (PEEP). Airway displacement and airway strains increased with increasing airflow rate, tidal volume and PEEP form mechanical ventilation. Among various waveforms considered, sine waveform provided the highest airflow velocity and airway pressure while descending waveform provided the lowest airway pressure, airway displacement and airway strains. These results combined with optimization suggest that it is possible to obtain a set of mechanical ventilation strategies to avoid lung injuries in patients.

  2. Postoperative Complications Leading to Death after Coagulum Pyelolithotomy in a Tetraplegic Patient: Can We Prevent Prolonged Ileus, Recurrent Intestinal Obstruction due to Adhesions Requiring Laparotomies, Chest Infection Warranting Tracheostomy, and Mechanical Ventilation?

    PubMed Central

    Vaidyanathan, Subramanian; Soni, Bakul; Singh, Gurpreet; Hughes, Peter

    2013-01-01

    A 22-year-old male sustained C-6 tetraplegia in 1992. In 1993, intravenous pyelography revealed normal kidneys. Suprapubic cystostomy was performed. He underwent open cystolithotomy in 2004 and 2008. In 2009, computed tomography revealed bilateral renal calculi. Coagulum pyelolithotomy of left kidney was performed. Pleura and peritoneum were opened. Peritoneum could not be closed. Following surgery, he developed pulmonary atelectasis; he required tracheostomy and mechanical ventilation. He did not tolerate nasogastric feeding. CT of abdomen revealed bilateral renal calculi and features of proximal small bowel obstruction. Laparotomy revealed small bowel obstruction due to dense inflammatory adhesions involving multiple small bowel loops which protruded through the defect in sigmoid mesocolon and fixed posteriorly over the area of previous intervention. All adhesions were divided. The wide defect in mesocolon was not closed. In 2010, this patient again developed vomiting and distension of abdomen. Laparotomy revealed multiple adhesions. He developed chest infection and required ventilatory support again. He developed pressure sores and depression. Later abdominal symptoms recurred. This patient's general condition deteriorated and he expired in 2011. Conclusion. Risk of postoperative complications could have been reduced if minimally invasive surgery had been performed instead of open surgery to remove stones from left kidney. Suprapubic cystostomy predisposed to repeated occurrence of stones in urinary bladder and kidneys. Spinal cord physicians should try to establish intermittent catheterisation regime in tetraplegic patients. PMID:23533931

  3. Mechanical ventilation for status asthmaticus in children.

    PubMed

    Dworkin, G; Kattan, M

    1989-04-01

    We retrospectively reviewed the time course of recovery of pediatric patients in status asthmaticus who were undergoing mechanical ventilation for life-threatening respiratory failure to evaluate the results with current medications and technology. Ten patients between 2 and 18 years of age underwent intubation on 20 occasions. Mechanical ventilation was maintained for a mean of 2 days. Positive end-expiratory pressure was introduced in the recovery phase to prevent hypoxemia. Twelve episodes (Group 1) involved intubation less than 48 hours; in eight episodes (group 2) the patients required ventilatory support greater than 48 hours. The two groups did not differ in regard to age, pharmacologic therapy, preintubation arterial blood gas data, or initial ventilator settings, but the rise in pH and fall in Paco2 differed significantly over the first 12 hours of therapy. In the group 2 patients, peak pressures were not increased greater than 60 cm H2O despite elevated Paco2 values, and aggressive sodium bicarbonate therapy for pH correction was not pursued. Complications were few and all patients survived. We conclude that asthma patients have variable resolution of airway obstruction during mechanical ventilation and that controlled hypoventilation can be a safe therapy for the patients with more severe obstruction.

  4. [Home mechanical ventilation: Invasive and noninvasive ventilation therapy for chronic respiratory failure].

    PubMed

    Huttmann, S E; Storre, J H; Windisch, W

    2015-06-01

    Home mechanical ventilation represents a valuable therapeutic option to improve alveolar ventilation in patients with chronic respiratory failure. For this purpose both invasive ventilation via tracheostomy and noninvasive ventilation via facemasks are available. The primary goal of home mechanical ventilation is a reduction of symptoms, improvement of quality of life and in many cases reduction of mortality. Elective establishment of home mechanical ventilation is typically provided for noninvasive ventilation in respect to clinical symptoms and partial pressure of carbon dioxide depending on the underlying disease. However, invasive mechanical ventilation is increasingly being used to continue ventilatory support in polymorbid patients following unsuccessful weaning. Recommendations and guidelines have been published by the German Respiratory Society (DGP).

  5. Leaky ryanodine receptors contribute to diaphragmatic weakness during mechanical ventilation

    PubMed Central

    Matecki, Stefan; Dridi, Haikel; Jung, Boris; Saint, Nathalie; Reiken, Steven R.; Scheuermann, Valérie; Mrozek, Ségolène; Umanskaya, Alisa; Petrof, Basil J.; Jaber, Samir; Marks, Andrew R.; Lacampagne, Alain

    2016-01-01

    Ventilator-induced diaphragmatic dysfunction (VIDD) refers to the diaphragm muscle weakness that occurs following prolonged controlled mechanical ventilation (MV). The presence of VIDD impedes recovery from respiratory failure. However, the pathophysiological mechanisms accounting for VIDD are still not fully understood. Here, we show in human subjects and a mouse model of VIDD that MV is associated with rapid remodeling of the sarcoplasmic reticulum (SR) Ca2+ release channel/ryanodine receptor (RyR1) in the diaphragm. The RyR1 macromolecular complex was oxidized, S-nitrosylated, Ser-2844 phosphorylated, and depleted of the stabilizing subunit calstabin1, following MV. These posttranslational modifications of RyR1 were mediated by both oxidative stress mediated by MV and stimulation of adrenergic signaling resulting from the anesthesia. We demonstrate in the murine model that such abnormal resting SR Ca2+ leak resulted in reduced contractile function and muscle fiber atrophy for longer duration of MV. Treatment with β-adrenergic antagonists or with S107, a small molecule drug that stabilizes the RyR1–calstabin1 interaction, prevented VIDD. Diaphragmatic dysfunction is common in MV patients and is a major cause of failure to wean patients from ventilator support. This study provides the first evidence to our knowledge of RyR1 alterations as a proximal mechanism underlying VIDD (i.e., loss of function, muscle atrophy) and identifies RyR1 as a potential target for therapeutic intervention. PMID:27457930

  6. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline.

    PubMed

    McKim, Douglas A; Road, Jeremy; Avendano, Monica; Abdool, Steve; Cote, Fabien; Duguid, Nigel; Fraser, Janet; Maltais, Fracois; 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 userfriendly 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.

  7. [Principles and function of mechanical ventilation: classification and modes of ventilators].

    PubMed

    Kelbel, C; Huntemann, M; Lorenz, J

    2006-04-01

    A spectrum of diseases is associated with the necessity for partial or total support of pulmonary ventilation. The insight into the function of ventilators and their modes reduces the spectrum of ventilatory support to a few basic principles. The knowledge enables the pulmonary intensivist to adapt mechanical ventilation to the individual patient's needs. This overview describes the technical aspects of mechanical ventilation and summarizes the variety of specific modes implied.

  8. 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.

  9. 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

  10. 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.

  11. The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation.

    PubMed

    Mohr, A M; Rutherford, E J; Cairns, B A; Boysen, P G

    2001-11-01

    The exact mechanism by which tracheostomy results in clinical improvement in respiratory function and liberation from mechanical ventilation remains unknown. Physiologic dead space, which includes both normal and abnormal components of non-gas exchange tidal volume, is a clinical measure of the efficiency of ventilation. Theoretically, tracheostomy should reduce dead space ventilation and improve pulmonary mechanics, thereby facilitating weaning from mechanical ventilation. This study compares arterial blood gases (ABG), pulmonary mechanics, including minute ventilation (VE) and dead space ventilation (Vd/Vt) within 24 hours before and after tracheostomy in 45 patients admitted to a surgical intensive care unit. There was no difference noted in patients' ABG or VE. Pre- and posttracheostomy change in Vd/Vt was negligible (50.7 and 10 vs. 51.9 and 11; p = NS). On subgroup analysis, those patients that were weaned from mechanical ventilation with 72 hours of tracheostomy (T3) were compared with those patients weaned from mechanical ventilation 5 days or more after tracheostomy (T+5). Again, no difference was found in pulmonary mechanics or Vd/Vt pre- and posttracheostomy. There is minimal improvement in pulmonary mechanics after tracheostomy. The change in physiologic dead space posttracheostomy does not predict the outcome of weaning from mechanical ventilation. Tracheostomy does allow better pulmonary toilet, and easier initiation and removal of mechanical ventilation and control of the upper airway.

  12. Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy.

    PubMed

    Hussain, Sabah N A; Mofarrahi, Mahroo; Sigala, Ioanna; Kim, Ho Cheol; Vassilakopoulos, Theodoros; Maltais, Francois; Bellenis, Ion; Chaturvedi, Rakesh; Gottfried, Stewart B; Metrakos, Peter; Danialou, Gawiyou; Matecki, Stefan; Jaber, Samir; Petrof, Basil J; Goldberg, Peter

    2010-12-01

    Controlled mechanical ventilation (CMV) results in atrophy of the human diaphragm. The autophagy-lysosome pathway (ALP) contributes to skeletal muscle proteolysis, but its contribution to diaphragmatic protein degradation in mechanically ventilated patients is unknown. To evaluate the autophagy pathway responses to CMV in the diaphragm and limb muscles of humans and to identify the roles of FOXO transcription factors in these responses. Muscle biopsies were obtained from nine control subjects and nine brain-dead organ donors. Subjects were mechanically ventilated for 2 to 4 hours and 15 to 276 hours, respectively. Activation of the ubiquitin-proteasome system was detected by measuring mRNA expressions of Atrogin-1, MURF1, and protein expressions of UBC2, UBC4, and the α subunits of the 20S proteasome (MCP231). Activation of the ALP was detected by electron microscopy and by measuring the expressions of several autophagy-related genes. Total carbonyl content and HNE-protein adduct formation were measured to assess oxidative stress. Total AKT, phosphorylated and total FOXO1, and FOXO3A protein levels were also measured. Prolonged CMV triggered activation of the ALP as measured by the appearance of autophagosomes in the diaphragm and increased expressions of autophagy-related genes, as compared with controls. Induction of autophagy was associated with increased protein oxidation and enhanced expression of the FOXO1 gene, but not the FOXO3A gene. CMV also triggered the inhibition of both AKT expression and FOXO1 phosphorylation. We propose that prolonged CMV causes diaphragm disuse, which, in turn, leads to activation of the ALP through oxidative stress and the induction of the FOXO1 transcription factor.

  13. Outcomes of Morbidly Obese Patients Receiving Invasive Mechanical Ventilation

    PubMed Central

    Kumar, Gagan; Majumdar, Tilottama; Jacobs, Elizabeth R.; Danesh, Valerie; Dagar, Gaurav; Deshmukh, Abhishek; Taneja, Amit

    2013-01-01

    Background: Critically ill, morbidly obese patients (BMI ≥ 40 kg/m2) are at high risk of respiratory failure requiring invasive mechanical ventilation (IMV). It is not clear if outcomes of critically ill, obese patients are affected by obesity. Due to limited cardiopulmonary reserve, they may have poor outcomes. However, literature to this effect is limited and conflicted. Methods: We used the Nationwide Inpatient Sample from 2004 to 2008 to examine the outcomes of morbidly obese people receiving IMV and compared them to nonobese people. We identified hospitalizations requiring IMV and morbid obesity using International Classification of Diseases, 9th Revision, Clinical Modification codes. Primary outcomes studied were inhospital mortality, rates of prolonged mechanical ventilation (≥ 96 h), and tracheostomy. Multivariable logistic regression was used to adjust for potential confounding variables. We also examined outcomes stratified by number of organs failing. Results: Of all hospitalized, morbidly obese people, 2.9% underwent IMV. Mean age, comorbidity score, and severity of illness were lower in morbidly obese people. The adjusted mortality was not significantly different in morbidly obese people (OR 0.89; 95% CI, 0.74-1.06). When stratified by severity of disease, there was a stepwise increase in risk for mortality among morbidly obese people relative to nonobese people (range: OR, 0.77; 95% CI, 0.58-1.01 for only respiratory failure, to OR, 4.14; 95% CI, 1.11-15.3 for four or more organs failing). Rates of prolonged mechanical ventilation were similar, but rate of tracheostomy (OR 2.19; 95% CI, 1.77-2.69) was significantly higher in patients who were morbidly obese. Conclusions: Morbidly obese people undergoing IMV have a similar risk for death as nonobese people if only respiratory failure is present. When more organs fail, morbidly obese people have increased risk for mortality compared with nonobese people. PMID:23349057

  14. Respiratory infections in patients undergoing mechanical ventilation.

    PubMed

    Rello, Jordi; Lisboa, Thiago; Koulenti, Despoina

    2014-09-01

    Lower respiratory tract infections in mechanically ventilated patients are a frequent cause of antibiotic treatment in intensive-care units. These infections present as severe sepsis or septic shock with respiratory dysfunction in intubated patients. Purulent respiratory secretions are needed for diagnosis, but distinguishing between pneumonia and tracheobronchitis is not easy. Both presentations are associated with longlasting mechanical ventilation and extended intensive-care unit stay, providing a rationale for antibiotic treatment initiation. Differentiation of colonisers from true pathogens is difficult, and microbiological data show Staphylococcus aureus and Pseudomonas aeruginosa to be of great concern because of clinical outcomes and therapeutic challenges. Key management issues include identification of the pathogen, choice of initial empirical antibiotic, and decisions with regard to the resolution pattern.

  15. 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

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

    PubMed

    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; Powers, Scott K

    2015-11-15

    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.

  17. [Consequences of mechanical ventilation on diaphragmatic function].

    PubMed

    Jung, B; Gleeton, D; Daurat, A; Conseil, M; Mahul, M; Rao, G; Matecki, S; Lacampagne, A; Jaber, S

    2015-04-01

    Mechanical ventilation is associated with ventilator-induced diaphragmatic dysfunction (VIDD) in animal models and also in humans. The main pathophysiological pathways implicated in VIDD seems to be related to muscle inactivity but may also be the consequence of high tidal volumes. Systemic insults from side effects of medication, infection, malnutrition and hypoperfusion also play a part. The diaphragm is caught in the cross-fire of ventilation-induced and systemic-induced dysfunctions. Intracellular consequences of VIDD include oxidative stress, proteolysis, impaired protein synthesis, autophagy activation and excitation-contraction decoupling. VIDD can be diagnosed at the bedside using non-invasive magnetic stimulation of the phrenic nerves which is the gold standard. Other techniques involve patient's participation such as respiratory function tests or ultrasound examination. At this date, only spontaneous ventilatory cycles and perhaps phrenic nerve stimulation appear to diminish the severity of VIDD in humans but several pathways are currently being examined using animal models. Specific pharmacological options are currently under investigation in animal models. Copyright © 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.

  18. 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.

  19. Oxygen Therapeutics and Mechanical Ventilation Advances.

    PubMed

    Weiss, Brian; Kaplan, Lewis J

    2017-04-01

    Advances in intensive care unit (ICU) therapeutics are plentiful and rooted in technological enhancements as well as recognition of patient care priorities. A plethora of new devices and modes are available for use to enhance patient safety and support liberation from mechanical ventilation while preserving oxygenation and carbon dioxide clearance. Increased penetrance of closed loop systems is one means to reduce care variation in appropriate populations. The intelligent design of the ICU space needs to integrate the footprint of that device and the data streaming from it into a coherent whole that supports patient, family, and caregivers. Published by Elsevier Inc.

  20. Design Features of Modern Mechanical Ventilators.

    PubMed

    MacIntyre, Neil

    2016-12-01

    A positive-pressure breath ideally should provide a VT that is adequate for gas exchange and appropriate muscle unloading while minimizing any risk for injury or discomfort. The latest generation of ventilators uses sophisticated feedback systems to sculpt positive-pressure breaths according to patient effort and respiratory system mechanics. Currently, however, these new control strategies are not totally closed-loop systems. This is because the automatic input variables remain limited, some clinician settings are still required, and the specific features of the perfect breath design still are not entirely clear. Despite these limitations, there are some rationale for many of these newer feedback features.

  1. [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.

  2. SIMPLIFIED METHODS FOR COMBINING MECHANICAL VENTILATION AND NATURAL INFILTRATION

    SciTech Connect

    Modera, M.; Peterson, F.

    1985-01-01

    During the past ten years, the means of ventilating single-family residences has received considerable attention. In many areas, the use of natural ventilation for infiltration has either come under close scrutiny, or has already been supplanted by mechanical ventilation systems. To evaluate the energy efficiency and ventilation effectiveness of both mechanical and natural ventilation strategies, both complex and simplified infiltration models are used. This paper examines the inaccuracies associated with using simplified models to compare ventilation strategies. Two simplified techniques for combining mechanical ventilation flows to the flows caused by wind and stack effects are examined. The simplified combination techniques are compared with the results obtained with an iterative flow-balance simulation. The flow-balance simulation determines the ventilation by balancing the incoming and outgoing flows under the pressure conditions resulting from the combination of wind effect, stack effect and mechanical ventilation. These comparisons result in three major conclusions: (1) the commonly used flow superposition technique (flow combination in quadrature) provides better estimates of the total flow than does a technique that takes into account measured flow exponents, (2) although flow combination in quadrature overpredicts ventilation when combining wind-induced and stack-induced flows, this is not the case when mechanical ventilation is added to the picture, and (3) a simple correction for the errors caused by the simplified flow superposition technique is not easy to achieve due to the large variations in error that occur with changes in wind direction and individual flow ratios.

  3. Mechanical ventilation, diaphragm weakness and weaning: A rehabilitation perspective

    PubMed Central

    Martin, A Daniel; Smith, Barbara; Gabrielli, Andrea

    2013-01-01

    Most patients are easily liberated from mechanical ventilation (MV) following resolution of respiratory failure and a successful trial of spontaneous breathing, but about 25% of patients experience difficult weaning. MV use leads to cellular changes and weakness, which has been linked to weaning difficulties and has been labeled ventilator induced diaphragm dysfunction (VIDD). Aggravating factors in human studies with prolonged weaning include malnutrition, chronic electrolyte abnormalities, hyperglycemia, excessive resistive and elastic loads, corticosteroids, muscle relaxant exposure, sepsis and compromised cardiac function. Numerous animal studies have investigated the effects of MV on diaphragm function. Virtually all of these studies have concluded that MV use rapidly leads to VIDD and have identified cellular and molecular mechanisms of VIDD. Molecular and functional studies on the effects of MV on the human diaphragm have largely confirmed the animal results and identified potential treatment strategies. Only recently have potential VIDD treatments been tested in humans, including pharmacologic interventions and diaphragm “training”. A limited number of human studies have found that specific diaphragm training can increase respiratory muscle strength in FTW patients and facilitate weaning, but larger, multicenter trials are needed. PMID:23692928

  4. Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective.

    PubMed

    Daniel Martin, A; Smith, Barbara K; Gabrielli, Andrea

    2013-11-01

    Most patients are easily liberated from mechanical ventilation (MV) following resolution of respiratory failure and a successful trial of spontaneous breathing, but about 25% of patients experience difficult weaning. MV use leads to cellular changes and weakness, which has been linked to weaning difficulties and has been labeled ventilator induced diaphragm dysfunction (VIDD). Aggravating factors in human studies with prolonged weaning include malnutrition, chronic electrolyte abnormalities, hyperglycemia, excessive resistive and elastic loads, corticosteroids, muscle relaxant exposure, sepsis and compromised cardiac function. Numerous animal studies have investigated the effects of MV on diaphragm function. Virtually all these studies have concluded that MV use rapidly leads to VIDD and have identified cellular and molecular mechanisms of VIDD. Molecular and functional studies on the effects of MV on the human diaphragm have largely confirmed the animal results and identified potential treatment strategies. Only recently potential VIDD treatments have been tested in humans, including pharmacologic interventions and diaphragm "training". A limited number of human studies have found that specific diaphragm training can increase respiratory muscle strength in FTW patients and facilitate weaning, but larger, multicenter trials are needed. Copyright © 2013 Elsevier B.V. All rights reserved.

  5. Nutritional support of the mechanically ventilated patient.

    PubMed

    Shikora, S A; Benotti, P N

    1997-03-01

    As with all critically ill patients, those requiring mechanical ventilation are susceptible to the wasting of illness and cannot survive without prompt nutritional support. It may be fair to say that the proper provision of nutrients, and in particular the avoidance of overfeeding, are even more crucial for this subset of critically ill patients. To maximize the overall benefits of feeding, it is crucial to provide the nutritional support early and enterally whenever possible. Therefore, the best strategy for early removal of the mechanical ventilatory support must include the timely and careful administration of nutrients, micronutrients, minerals, vitamins, and fluid, in conjunction with standard intensive care therapeutics and the appropriate respiratory muscle-strengthening program.

  6. An Overview of the Predictor Standard Tools for Patient Weaning from Mechanical Ventilation

    PubMed Central

    Dehghani, Acieh; Abdeyazdan, Gholamhossein; Davaridolatabadi, Elham

    2016-01-01

    Most patients staying in the intensive care unit (ICU) require respiratory support through a ventilator. Since prolonged mechanical ventilation and weaning from the ventilator without criteria or at the inappropriate time can result in many complications, it is required that patients be weaned off the ventilator as soon as possible. This study was conducted to investigate a few standard tools that predict successful and timely weaning of patients from the ventilator. In the literature, SOFA and APACHE II scores, along with various tools, including Burn, Morganroth, and Corgian, have been used in weaning patients from the ventilator. In most of these studies, the increase or decrease in the APACHE II score was correlated with the patient’s weaning time, and this score could be used as a criterion for weaning. Several authors have expressed their belief that the SOFA score in the ICU is a good indicator of the prognosis of patient’s weaning from the ventilator, length of stay, mortality, and rate of recovery. Several studies have compared SOFA and APACHE II scores and have shown that there is a positive correlation between the SOFA and APACHE II scores and that both mortality and dependence on the ventilator are related to these two scores. Another tool is Burn’s weaning program. A higher Burn score indicates successful weaning off of the ventilator, successful extubation, lower length of mechanical ventilation, and shorter stay in the hospital. However, the capabilities of the Morganroth scale and the Gluck and Corgian scoring systems were evaluated only for successful weaning off of the ventilator, and a decrease in the Morganroth and Gluck scores indicated successful weaning. PMID:27054004

  7. Development and Validation of a Mortality Prediction Model for Patients Receiving 14 Days of Mechanical Ventilation.

    PubMed

    Hough, Catherine L; Caldwell, Ellen S; Cox, Christopher E; Douglas, Ivor S; Kahn, Jeremy M; White, Douglas B; Seeley, Eric J; Bangdiwala, Shrikant I; Rubenfeld, Gordon D; Angus, Derek C; Carson, Shannon S

    2015-11-01

    The existing risk prediction model for patients requiring prolonged mechanical ventilation is not applicable until after 21 days of mechanical ventilation. We sought to develop and validate a mortality prediction model for patients earlier in the ICU course using data from day 14 of mechanical ventilation. Multicenter retrospective cohort study. Forty medical centers across the United States. Adult patients receiving at least 14 days of mechanical ventilation. None. Predictor variables were measured on day 14 of mechanical ventilation in the development cohort and included in a logistic regression model with 1-year mortality as the outcome. Variables were sequentially eliminated to develop the ProVent 14 model. This model was then generated in the validation cohort. A simplified prognostic scoring rule (ProVent 14 Score) using categorical variables was created in the development cohort and then tested in the validation cohort. Model discrimination was assessed by the area under the receiver operator characteristic curve. Four hundred ninety-one patients and 245 patients were included in the development and validation cohorts, respectively. The most parsimonious model included age, platelet count, requirement for vasopressors, requirement for hemodialysis, and nontrauma admission. The area under the receiver operator characteristic curve for the ProVent 14 model using continuous variables was 0.80 (95% CI, 0.76-0.83) in the development cohort and 0.78 (95% CI, 0.72-0.83) in the validation cohort. The ProVent 14 Score categorized age at 50 and 65 years old and platelet count at 100×10(9)/L and had similar discrimination as the ProVent 14 model in both cohorts. Using clinical variables available on day 14 of mechanical ventilation, the ProVent 14 model can identify patients receiving prolonged mechanical ventilation with a high risk of mortality within 1 year.

  8. Optimizing Communication in Mechanically Ventilated Patients

    PubMed Central

    Pandian, Vinciya; Smith, Christine P.; Cole, Therese Kling; Bhatti, Nasir I.; Mirski, Marek A.; Yarmus, Lonny B.; Feller-Kopman, David J.

    2014-01-01

    Purpose To describe the types of talking tracheostomy tubes available, present four case studies of critically ill patients who used a specialized tracheostomy tube to improve speech, discuss their advantages and disadvantages, propose patient selection criteria, and provide practical recommendations for medical care providers. Methods Retrospective chart review of patients who underwent tracheostomy in 2010. Results Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%) received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy. Among the percutaneous tracheostomy patients, speech-language pathologists were consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients received a talking tracheostomy tube, and all four were able to speak successfully while on the mechanical ventilator even though they were unable to tolerate cuff deflation. Conclusions Talking tracheostomy tubes allow patients who are unable to tolerate-cuff deflation to achieve phonation. Our experience with talking tracheostomy tubes suggests that clinicians should consider their use for patients who cannot tolerate cuff deflation. PMID:25429193

  9. Ofloxacin pharmacokinetics in mechanically ventilated patients.

    PubMed Central

    Martin, C; Lambert, D; Bruguerolle, B; Saux, P; Freney, J; Fleurette, J; Meugnier, H; Gouin, F

    1991-01-01

    The pharmacokinetics of ofloxacin were studied in 12 intensive care patients, 6 of whom were under controlled mechanical ventilation. All patients had a creatinine clearance of greater than 80 ml/min per 1.73 m2. They were given 3 mg of ofloxacin per kg of body weight intravenously at a constant flow rate in 30 min twice a day for 7 days. Pharmacokinetic studies were performed on days 1 and 7. Between days 1 and 7, significant increases in the alpha (distribution) and beta (elimination) phase half-lives, the area under the serum concentration-time curve, and peak and trough levels in serum were observed, together with a marked decrease (greater than 50%) in total body clearance. Possible contributing factors for alteration of ofloxacin pharmacokinetics in ventilated patients were patient age, liver dysfunction, drug interaction, and drug accumulation in a deep compartment. This study shows that in intensive care patients the pharmacokinetics of ofloxacin differ from those reported for healthy volunteers. PMID:1929329

  10. Exercise oscillatory ventilation: Mechanisms and prognostic significance

    PubMed Central

    Dhakal, Bishnu P; Lewis, Gregory D

    2016-01-01

    Alteration in breathing patterns characterized by cyclic variation of ventilation during rest and during exercise has been recognized in patients with advanced heart failure (HF) for nearly two centuries. Periodic breathing (PB) during exercise is known as exercise oscillatory ventilation (EOV) and is characterized by the periods of hyperpnea and hypopnea without interposed apnea. EOV is a non-invasive parameter detected during submaximal cardiopulmonary exercise testing. Presence of EOV during exercise in HF patients indicates significant impairment in resting and exercise hemodynamic parameters. EOV is also an independent risk factor for poor prognosis in HF patients both with reduced and preserved ejection fraction irrespective of other gas exchange variables. Circulatory delay, increased chemosensitivity, pulmonary congestion and increased ergoreflex signaling have been proposed as the mechanisms underlying the generation of EOV in HF patients. There is no proven treatment of EOV but its reversal has been noted with phosphodiesterase inhibitors, exercise training and acetazolamide in relatively small studies. In this review, we discuss the mechanistic basis of PB during exercise and the clinical implications of recognizing PB patterns in patients with HF. PMID:27022457

  11. 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.

  12. Mechanical Ventilation-Induced Oxidative Stress in the Diaphragm

    PubMed Central

    Falk, Darin J.; Kavazis, Andreas N.; Whidden, Melissa A.; Smuder, Ashley J.; McClung, Joseph M.; Hudson, Matthew B.

    2011-01-01

    Background: Prolonged mechanical ventilation (MV) results in a rapid onset of diaphragmatic atrophy that is primarily due to increased proteolysis. Although MV-induced protease activation can involve several factors, it is clear that oxidative stress is a required signal for protease activation in the diaphragm during prolonged MV. However, the oxidant-producing pathways in the diaphragm that contribute to MV-induced oxidative stress remain unknown. We have demonstrated that prolonged MV results in increased diaphragmatic expression of a key stress-sensitive enzyme, heme oxygenase (HO)-1. Paradoxically, HO-1 can function as either a pro-oxidant or an antioxidant, and the role that HO-1 plays in MV-induced diaphragmatic oxidative stress is unknown. We tested the hypothesis that HO-1 acts as a pro-oxidant in the diaphragm during prolonged MV. Methods: To determine whether HO-1 functions as a pro-oxidant or an antioxidant in the diaphragm during MV, we assigned rats into three experimental groups: (1) a control group, (2) a group that received 18 h of MV and saline solution, and (3) a group that received 18 h of MV and was treated with a selective HO-1 inhibitor. Indices of oxidative stress, protease activation, and fiber atrophy were measured in the diaphragm. Results: Inhibition of HO-1 activity did not prevent or exacerbate MV-induced diaphragmatic oxidative stress (as indicated by biomarkers of oxidative damage). Further, inhibition of HO-1 activity did not influence MV-induced protease activation or myofiber atrophy in the diaphragm. Conclusions: Our results indicate that HO-1 is neither a pro-oxidant nor an antioxidant in the diaphragm during MV. Furthermore, our findings reveal that HO-1 does not play an important role in MV-induced protease activation and diaphragmatic atrophy. PMID:21106654

  13. Respiratory severity score on day of life 30 is predictive of mortality and the length of mechanical ventilation in premature infants with protracted ventilation.

    PubMed

    Malkar, Manish B; Gardner, William P; Mandy, George T; Stenger, Michael R; Nelin, Leif D; Shepherd, Edward G; Welty, Stephen E

    2015-04-01

    We tested the hypothesis that Respiratory Severity Score (RSS) on day of life 30 is predictive of mortality and length of mechanical ventilation in premature infants on prolonged mechanical ventilation. A retrospective chart review was performed using the Nationwide Children's Hospital medical record and Vermont-Oxford Network databases. The primary outcome variable was survival to hospital discharge and the secondary outcome was length of mechanical ventilation after day of life 30. We identified 199 neonates admitted to Nationwide Children's Hospital between 2004 and 2007 with birth weight less than 1,500 g that received prolonged mechanical ventilation in the first 30 days of their life. A total of 184 infants were included in the analysis, excluding 14 patients with congenital anomalies and one infant with incomplete data. RSS on day of life 30 was significantly greater in the group of infants that died compared to those that survived (P = 0.003, 95% CI = [0.08, 0.40]). Further analysis demonstrated that the maximum difference in mortality was obtained with a threshold RSS of 6. Of the 109 patients who had RSS less than 6 on day of life 30, mortality rate was 4.6% (5/109) while those greater than or equal to 6 had a mortality rate of 21.3% (16/75). Both Kaplan-Meier survival curves comparing mortality and length of mechanical ventilation in infants with RSS < 6 versus those with RSS ≥ 6 demonstrated strong associations between RSS on day of life 30 and survival (P = 0.002) and length of ventilation after day of life 30 (P < 0.001). RSS ≥ 6 on day of life 30 is associated with higher mortality and longer period of mechanical ventilation in premature infants requiring mechanical ventilation through 30 days of life. © 2014 Wiley Periodicals, Inc.

  14. Drug-induced QT interval prolongation: mechanisms and clinical management

    PubMed Central

    Nachimuthu, Senthil; Assar, Manish D.

    2012-01-01

    The prolonged QT interval is both widely seen and associated with the potentially deadly rhythm, Torsades de Pointes (TdP). While it can occur spontaneously in the congenital form, there is a wide array of drugs that have been implicated in the prolongation of the QT interval. Some of these drugs have either been restricted or withdrawn from the market due to the increased incidence of fatal polymorphic ventricular tachycardia. The list of drugs that cause QT prolongation continues to grow, and an updated list of specific drugs that prolong the QT interval can be found at www.qtdrugs.org. This review focuses on the mechanism of drug-induced QT prolongation, risk factors for TdP, culprit drugs, prevention and monitoring of prolonged drug-induced QT prolongation and treatment strategies. PMID:25083239

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

    PubMed Central

    Yokoyama, Takeshi

    2016-01-01

    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 (MAXMV). To assess the independent association of MAXMV 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 MAXMV on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAXMV ≥ 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 MAXMV of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAXMV 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 MAXMV in both categories of ICU admission. A significant association between MAXMV 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. PMID:27822946

  16. Load-distributing band improves ventilation and hemodynamics during resuscitation in a porcine model of prolonged cardiac arrest

    PubMed Central

    2012-01-01

    Background The use of mechanical cardiopulmonary resuscitation (CPR) has great potential for the clinical setting. The purpose of present study is to compare the hemodynamics and ventilation during and after the load-distributing band CPR, versus the manual CPR in a porcine model of prolonged cardiac arrest, and to investigate the influence of rescue breathing in different CPR protocols. Methods Sixty-four male pigs (n = 16/group), weighing 30 ± 2 kg, were induced ventricular fibrillation and randomized into four resuscitation groups: continuous load-distributing band CPR without rescue ventilation (C-CPR), load-distributing band 30:2 CPR (A-CPR), load-distributing band CPR with continuous rescue breathing (10/min) (V-CPR) or manual 30:2 CPR (M-CPR). Respiratory variables and hemodynamics were recorded continuously; blood gas was analyzed. Results Tidal volume produced by compressions in the A-, C- and V-CPR groups were significantly higher compared with the M-CPR group (all p < 0.05). Coronary perfusion pressure of the V-CPR group was significantly lower than the C-CPR group (p < 0.01), but higher than the M-CPR group. The increasing of lung dead space after restoration of spontaneous circulation was significantly greater in the M-CPR group compared with the A-, C- and V-CPR groups (p < 0.01). Blood pH gradually decreased and was lower in the M-CPR group than that in the A-, C- and V-CPR groups (p < 0.01). PaO2 of the A-, C- and V-CPR groups were significantly higher and PaCO2 were significantly lower compared with the M-CPR (both p < 0.05). Cerebral performance categories were better in the A-, C- and V-CPR groups compared with the M-CPR group (p < 0.0001). Conclusions The load-distributing band CPR significantly improved respiratory parameters during resuscitation by augmenting passive ventilation, and significantly improved coronary perfusion pressure. The volume of ventilation produced by the load-distributing band CPR was

  17. The use of 2% chlorhexidine gel and toothbrushing for oral hygiene of patients receiving mechanical ventilation: effects on ventilator-associated pneumonia

    PubMed Central

    Meinberg, Maria Cristina de Avila; Cheade, Maria de Fátima Meinberg; Miranda, Amanda Lucia Dias; Fachini, Marcela Mascaro; Lobo, Suzana Margareth

    2012-01-01

    Objective To evaluate the effects of oral chlorhexidine hygiene with toothbrushing on the rate of ventilator-associated pneumonia in a mixed population of critically ill patients under prolonged mechanical ventilation. Methods Prospective, randomized, and placebo-controlled pilot study. Patients who were receiving mechanical ventilation, had been admitted less than 24 hours prior, and were anticipated to require mechanical ventilation for more than 72 hours were included in the study. The patients were randomly divided into one of the following groups: chlorhexidine hygiene with toothbrushing or a placebo group (gel with the same color and consistency and toothbrushing). Results The planned interim analysis was conducted using 52 patients, and the study was terminated prematurely. In total, 28 patients were included in the chlorhexidine / toothbrushing group, and 24 patients were included in the placebo group. Ventilator-associated pneumonia occurred in 45.8% of the placebo group and in 64.3% of the chlorhexidine hygiene with toothbrushing group (RR=1.4; 95% CI=0.83-2.34; p=0.29). Conclusion Because the study was terminated due to futility, it was not possible to evaluate the impact of oral hygiene using 2% chlorhexidine and toothbrushing on the incidence of ventilator-associated pneumonia in this heterogeneous population of critical patients receiving long-term mechanical ventilation, and no beneficial effect was observed for this intervention. PMID:23917935

  18. [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.

  19. Mechanical ventilation triggers hippocampal apoptosis by vagal and dopaminergic pathways.

    PubMed

    González-López, Adrián; López-Alonso, Inés; Aguirre, Alina; Amado-Rodríguez, Laura; Batalla-Solís, Estefanía; Astudillo, Aurora; Tomás-Zapico, Cristina; Fueyo, Antonio; dos Santos, Claudia C; Talbot, Konrad; Albaiceta, Guillermo M

    2013-09-15

    Critically ill patients frequently develop neuropsychological disturbances including acute delirium or memory impairment. The need for mechanical ventilation is a risk factor for these adverse events, but a mechanism that links lung stretch and brain injury has not been identified. To identify the mechanisms that lead to brain dysfunction during mechanical ventilation. Brains from mechanically ventilated mice were harvested, and signals of apoptosis and alterations in the Akt survival pathway were studied. These measurements were repeated in vagotomized or haloperidol-treated mice, and in animals intracerebroventricularly injected with selective dopamine-receptor blockers. Hippocampal slices were cultured and treated with micromolar concentrations of dopamine, with or without dopamine receptor blockers. Last, levels of dysbindin, a regulator of the membrane availability of dopamine receptors, were assessed in the experimental model and in brain samples from ventilated patients. Mechanical ventilation triggers hippocampal apoptosis as a result of type 2 dopamine receptor activation in response to vagal signaling. Activation of these receptors blocks the Akt/GSK3β prosurvival pathway and activates the apoptotic cascade, as demonstrated in vivo and in vitro. Vagotomy, systemic haloperidol, or intracerebroventricular raclopride (a type 2 dopamine receptor blocker) ameliorated this effect. Moreover, ventilation induced a concomitant change in the expression of dysbindin-1C. These results were confirmed in brain samples from ventilated patients. These results prove the existence of a pathogenic mechanism of lung stretch-induced hippocampal apoptosis that could explain the neurological changes in ventilated patients and may help to identify novel therapeutic approaches.

  20. [Organization of mechanical ventilation in French Intensive care units].

    PubMed

    Montravers, P; Ichai, C; Dupont, H; Payen, J F; Orliaguet, G; Blanchet, P; Malledant, Y; Albanèse, J; Asehnoune, K; Bastien, O; Collange, O; Duranteau, J; Garrigues, B; Lepape, A; Paugam-Burtz, C

    2013-11-01

    To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents. Declarative survey. Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions. Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1-50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU. This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

  1. 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

  2. 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.

  3. 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.

  4. Modern non-invasive mechanical ventilation turns 25.

    PubMed

    Díaz Lobato, Salvador; Mayoralas Alises, Sagrario

    2013-11-01

    The history of non-invasive mechanical ventilation goes back more than 100 years, but it was not until 1987 when what we could call "modern" non-invasive mechanical ventilation was developed. The description of Delaubier and Rideau of a patient with Duchenne's disease who had been effectively ventilated through a nasal mask marked the start of a new era in the history of non-invasive mechanical ventilation. Over these last 25years, we have witnessed exponential growth in its use, field of activity and technological advances on an exciting fast-paced track. We believe that it is time to review the main milestones that have marked the development of non-invasive mechanical ventilation to date, while paying homage to this therapeutic method that has contributed so much to the advancement of respiratory medicine in the last 25years.

  5. The Influence of Fluid Overload on the Length of Mechanical Ventilation in Pediatric Congenital Heart Surgery.

    PubMed

    Sampaio, Tatiana Z A L; O'Hearn, Katie; Reddy, Deepti; Menon, Kusum

    2015-12-01

    Fluid overload and prolonged mechanical ventilation lead to worse outcomes in critically ill children. However, the association between these variables in children following congenital heart surgery is unknown. The objectives of this study were to describe the association between fluid overload and duration of mechanical ventilation, oxygen requirement and radiologic findings of pulmonary and chest wall edema. This study is a retrospective chart review of patients who underwent congenital heart surgery between June 2010 and December 2013. Univariate and multivariate associations between maximum cumulative fluid balance and length of mechanical ventilation and OI were tested using the Spearman correlation test and multiple linear regression models, respectively. There were 85 eligible patients. Maximum cumulative fluid balance was associated with duration of mechanical ventilation (adjusted analysis beta coefficient = 0.53, CI 0.38-0.66, P < 0.001), length of stay in the pediatric intensive care unit (Spearman's correlation = 0.45, P < 0.001), and presence of chest wall edema and pleural effusions on chest radiograph (Mann-Whitney test, P = 0.003). Amount of red blood cells transfused and use of nitric oxide were independently associated with increased duration of mechanical ventilation (P = 0.012 and 0.014, respectively). Fluid overload is associated with prolonged duration of mechanical ventilation and PICU length of stay after congenital heart surgery. Fluid overload was also associated with physiological markers of respiratory restriction. A randomized controlled trial of a restrictive versus liberal fluid replacement strategy is necessary in this patient population, but in the meantime, accumulating observational evidence suggests that cautious use of fluid in the postoperative care may be warranted.

  6. Risk factors and prognosis of pain events during mechanical ventilation: a retrospective study.

    PubMed

    Yamashita, Ayahiro; Yamasaki, Masaki; Matsuyama, Hiroki; Amaya, Fumimasa

    2017-01-01

    Pain assessment is highly recommended in patients receiving mechanical ventilation. However, pain intensity and its impact on outcomes in these patients remain obscure. We collected the results of routine pain assessments, utilizing the behavioral pain scale (BPS), from 151 patients receiving mechanical ventilation. Risk factors associated with a pain event, defined as BPS of >5, and its impact on patient outcomes were investigated. A total of 151 consecutive adult patients receiving mechanical ventilation for more than 24 h in a single 10-bed ICU were enrolled in this study. The highest BPS within 48 h after the initiation of mechanical ventilation was collected, as well as information about the patients' characteristics and medication received. We also recorded patient outcomes, including time to successful weaning from mechanical ventilation, time to successful ICU discharge, and 30-day in-hospital mortality. Multivariate logistic regression analysis was used to determine factors independently associated with patients with a BPS of >5. Clinical outcomes were also assessed using multivariate logistic regression analysis, correcting for risk factors. We analyzed 151 patients. The median highest BPS was 4. The percentage of patients who recorded a BPS of >5 was 19.9% (n = 30). Multivariate logistic regression analysis revealed that the disuse of fentanyl and inotropic support was an independent predictor of pain event. Multivariable Cox regression analysis suggested that the development of a BPS of >5 was associated with increased mortality and a not statistically significant trend towards prolonged mechanical ventilation. A significant proportion of ventilated patients experienced a BPS of >5 soon after the initiation of mechanical ventilation. Disuse of fentanyl and use of inotropic agents increased the risk of developing a BPS of >5 during mechanical ventilation. An association between adequate analgesia and improved patient outcomes provides a rationale

  7. Assessment of the effect of continuous sedation with mechanical ventilation on adrenal insufficiency in patients with traumatic brain injury.

    PubMed

    Li, Min; Zhang, Ying; Wu, Kang-Song; Hu, Ying-Hong

    2016-03-01

    The aim of this study was to assess the effect of continuous propofol sedation plus prolonged mechanical ventilation on adrenal insufficiency (AI) in patients with traumatic brain injury (TBI). Eighty-five adult patients diagnosed with moderate TBI (Glasgow Coma Scale (GCS) score 9-13) from October 2011 to October 2012 were included in this prospective study. The patients comprised three groups: no mechanical ventilation and sedation (n=27), mechanical ventilation alone (n=24) and mechanical ventilation plus sedation (n=34). The low-dose short Synacthen test was performed at 8:00 on the first, third, and fifth days after TBI. Logistic regression analysis was performed to identify factors affecting the use of mechanical ventilation and sedation, and the incidence of AI. On the fifth day after injury, the mean baseline cortisol and simulated cortisol levels were significantly lower in the mechanical ventilation plus sedation group compared with the other two groups. Multivariate regression analysis showed that the Acute Physiology and Chronic Health Evaluation (APACHE) score was independently associated with treatment with mechanical ventilation and sedation compared to mechanical ventilation alone. Furthermore, hypoxemia on admission and shock were associated with the development of AI. The findings showed that sedation is associated with an increased incidence of AI. Patients with TBI who are treated with continuous sedation should be monitored for AI carefully.

  8. Mechanical ventilation weaning in inclusion body myositis: feasibility of isokinetic inspiratory muscle training as an adjunct therapy.

    PubMed

    Cordeiro de Souza, Leonardo; Campos, Josué Felipe; Daher, Leandro Possidente; Furtado da Silva, Priscila; Ventura, Alex; do Prado, Pollyana Zamborlini; Brasil, Daniele; Mendonça, Debora; Lugon, Jocemir Ronaldo

    2014-01-01

    Inclusion body myositis is a rare myopathy associated with a high rate of respiratory complications. This condition usually requires prolonged mechanical ventilation and prolonged intensive care stay. The unsuccessful weaning is mainly related to respiratory muscle weakness that does not promptly respond to immunosuppressive therapy. We are reporting a case of a patient in whom the use of an inspiratory muscle-training program which started after a two-week period of mechanical ventilation was associated with a successful weaning in one week and hospital discharge after 2 subsequent weeks.

  9. Mechanical Ventilation Weaning in Inclusion Body Myositis: Feasibility of Isokinetic Inspiratory Muscle Training as an Adjunct Therapy

    PubMed Central

    Campos, Josué Felipe; Daher, Leandro Possidente; Ventura, Alex; do Prado, Pollyana Zamborlini; Brasil, Daniele; Mendonça, Debora; Lugon, Jocemir Ronaldo

    2014-01-01

    Inclusion body myositis is a rare myopathy associated with a high rate of respiratory complications. This condition usually requires prolonged mechanical ventilation and prolonged intensive care stay. The unsuccessful weaning is mainly related to respiratory muscle weakness that does not promptly respond to immunosuppressive therapy. We are reporting a case of a patient in whom the use of an inspiratory muscle-training program which started after a two-week period of mechanical ventilation was associated with a successful weaning in one week and hospital discharge after 2 subsequent weeks. PMID:25147743

  10. Respiratory mechanics to understand ARDS and guide mechanical ventilation.

    PubMed

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

    2017-10-02

    As precision medicine is becoming standard of care to select tailored rather than average treatments, physiological measurements might represent the first step to apply personalized therapy in the intensive care unit (ICU). Systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step towards this direction for two main reasons. 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, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support 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. © 2017 Institute of Physics and Engineering in Medicine.

  11. 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

  12. Ammonia emissions from two mechanically ventilated UK livestock buildings

    NASA Astrophysics Data System (ADS)

    Demmers, T. G. M.; Burgess, L. R.; Short, J. L.; Phillips, V. R.; Clark, J. A.; Wathes, C. M.

    Ammonia emission rates from livestock buildings are required to construct an accurate emission inventory for the UK. Ventilation and ammonia emission rates from a fattening pig unit and a broiler house, both mechanically ventilated, were estimated using fan wheel anemometers and thermal converters with a chemiluminescence NO x-analyser to measure the ventilation rate and the ammonia concentration, respectively. The estimated ammonia emission factors were 46.9 and 16.6 kg lu -1 a -1 for the fattening pig unit and the broiler house, respectively. Both emission factors were within the range reported in the literature. A tracer gas (CO) method, based on a constant tracer release rate, was validated for measuring ventilation rates from naturally ventilated livestock buildings. Air inlets and outlets were identified using the air temperature or tracer concentration in the opening. Tracer concentration was found to be a more suitable criterion than temperature. In both houses, a significant correlation between the estimated ventilation rate using the tracer method and the measured ventilation rate using fan wheel anemometers was found. The ventilation rate was underestimated by 12 and 6% for the piggery and broiler house, respectively. The instantaneous ammonia emission derived from the tracer gas method was lower than the ammonia emission derived from the fan wheel anemometer method by 14 and 16% for the piggery and broiler house, respectively. The ventilation and ammonia emission estimates using the tracer method were within acceptable range from the ventilation and emission rates measured using measuring fans, but because of its accuracy and simplicity the fan wheel anemometer method is preferred for long-term measurements of ventilation rate in mechanically ventilated buildings.

  13. 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…

  14. 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…

  15. Variability in home mechanical ventilation prescription.

    PubMed

    Escarrabill, Joan; Tebé, Cristian; Espallargues, Mireia; Torrente, Elena; Tresserras, Ricard; Argimón, J

    2015-10-01

    Few studies have analyzed the prevalence and accessibility of home mechanical ventilation (HMV). The aim of this study was to characterize the prevalence of HMV and variability in prescriptions from administrative data. Prescribing rates of HMV in the 37 healthcare sectors of the Catalan Health Service were compared from billing data from 2008 to 2011. Crude accumulated activity rates (per 100,000 population) were calculated using systematic component of variation (SCV) and empirical Bayes (EB) methods. Standardized activity ratios (SAR) were described using a map of healthcare sectors. A crude rate of 23 HMV prescriptions per 100,000 population was observed. Rates increase with age and have increased by 39%. Statistics measuring variation not due to chance show a high variation in women (CSV=0.20 and EB=0.30) and in men (CSV=0.21 and EB=0.40), and were constant over time. In a multilevel Poisson model, hospitals with a chest unit were associated with a greater number of cases (beta=0.68, P<.0001). High variability in prescribing HMV can be explained, in part, by the attitude of professionals towards treatment and accessibility to specialist centers with a chest unit. Analysis of administrative data and variability mapping help identify unexplained variations and, in the absence of systematic records, are a feasible way of tracking treatment. Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.

  16. A Porcine Model for Initial Surge Mechanical Ventilator Assessment and Evaluation of Two Limited Function Ventilators

    PubMed Central

    Dickson, Robert P; Hotchkin, David L; Lamm, Wayne JE; Hinkson, Carl; Pierson, David J; Glenny, Robb W; Rubinson, Lewis

    2013-01-01

    Objective To adapt an animal model of acute lung injury for use as a standard protocol for a screening, initial evaluation of limited function, or “surge,” ventilators for use in mass casualty scenarios. Design Prospective, experimental animal study. Setting University research laboratory. Subjects 12 adult pigs. Interventions 12 spontaneously breathing pigs (6 in each group) were subjected to acute lung injury/acute respiratory distress syndrome (ALI/ARDS) via pulmonary artery infusion of oleic acid. Following development of respiratory failure, animals were mechanically ventilated with a limited function ventilator (Simplified Automatic Ventilator [SAVe] I or II; Automedx) for one hour or until the ventilator could not support the animal. The limited function ventilator was then exchanged for a full function ventilator (Servo 900C; Siemens). Measurements and Main Results Reliable and reproducible levels of ALI/ARDS were induced. The SAVe I was unable to adequately oxygenate 5 animals, with PaO2 (52.0 ± 11.1 torr) compared to the Servo (106.0 ± 25.6 torr; p=0.002). The SAVe II was able to oxygenate and ventilate all 6 animals for one hour with no difference in PaO2 (141.8 ± 169.3 torr) compared to the Servo (158.3 ± 167.7 torr). Conclusions We describe a novel in vivo model of ALI/ARDS that can be used to initially screen limited function ventilators considered for mass respiratory failure stockpiles, and is intended to be combined with additional studies to defintively assess appropriateness for mass respiratory failure. Specifically, during this study we demonstrate that the SAVe I ventilator is unable to provide sufficient gas exchange, while the SAVe II, with several more functions, was able to support the same level of hypoxemic respiratory failure secondary to ALI/ARDS for one hour. PMID:21187747

  17. Mechanisms of ventilator-induced lung injury in healthy lungs.

    PubMed

    Silva, Pedro Leme; Negrini, Daniela; Rocco, Patricia Rieken Macêdo

    2015-09-01

    Mechanical ventilation is an essential method of patient support, but it may induce lung damage, leading to ventilator-induced lung injury (VILI). VILI is the result of a complex interplay among various mechanical forces that act on lung structures, such as type I and II epithelial cells, endothelial cells, macrophages, peripheral airways, and the extracellular matrix (ECM), during mechanical ventilation. This article discusses ongoing research focusing on mechanisms of VILI in previously healthy lungs, such as in the perioperative period, and the development of new ventilator strategies for surgical patients. Several experimental and clinical studies have been conducted to evaluate the mechanisms of mechanotransduction in each cell type and in the ECM, as well as the role of different ventilator parameters in inducing or preventing VILI. VILI may be attenuated by reducing the tidal volume; however, the use of higher or lower levels of positive end-expiratory pressure (PEEP) and recruitment maneuvers during the perioperative period is a matter of debate. Many questions concerning the mechanisms of VILI in surgical patients remain unanswered. The optimal threshold value of each ventilator parameter to reduce VILI is also unclear. Further experimental and clinical studies are necessary to better evaluate ventilator settings during the perioperative period in different types of surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.

  18. Variability in Mechanical Ventilation: What's All the Noise About?

    PubMed

    Naik, Bhiken I; Lynch, Carl; Durbin, Charles G

    2015-08-01

    Controlled mechanical ventilation is characterized by a fixed breathing frequency and tidal volume. Physiological and mathematical models have demonstrated the beneficial effects of varying tidal volume and/or inspiratory pressure during positive-pressure ventilation. The addition of noise (random changes) to a monotonous nonlinear biological system, such as the lung, induces stochastic resonance that contributes to the recruitment of collapsed alveoli and atelectatic lung segments. In this article, we review the mechanism of physiological pulmonary variability, the principles of noise and stochastic resonance, and the emerging understanding that there are beneficial effects of variability during mechanical ventilation.

  19. Pressure versus volume controlled modes in invasive mechanical ventilation.

    PubMed

    Garnero, A J; Abbona, H; Gordo-Vidal, F; Hermosa-Gelbard, C

    2013-05-01

    The first generation of mechanical ventilators were controlled and cycled by pressure. Unfortunately, they did not allow control of the delivered tidal volume under changes in the dynamics of the respiratory system. This led to a second generation of ventilators that allowed volume control, hence favoring the ventilatory strategy based on normalization of the arterial gases. Studies conducted in the 1980s which related lung injury to the high ventilator pressures utilized while treating acute respiratory distress syndrome patients renewed interest in pressure-controlled mechanical ventilation. In addition, new evidence became available, leading to the development of pulmonary protective strategies aiming at preventing the progression of ventilator-induced lung injury. This review provides a detailed description of the control of pressure or volume using certain ventilatory modes, and offers a general view of their advantages and disadvantages, based on the latest available evidence. Copyright © 2012 Elsevier España, S.L. y SEMICYUC. All rights reserved.

  20. Dementia and Outcomes of Mechanical Ventilation.

    PubMed

    Lagu, Tara; Zilberberg, Marya D; Tjia, Jennifer; Shieh, Meng-Shiou; Stefan, Mihaela; Pekow, Penelope S; Lindenauer, Peter K

    2016-10-01

    To describe the effect of dementia on hospital outcomes of individuals requiring invasive mechanical ventilation (IMV). Retrospective cohort study. 2011 Nationwide Inpatient Sample. Hospitalized individuals with and without dementia undergoing IMV. The adjusted predicted probability of undergoing IMV was examined in individuals with and without dementia. Then the dataset was limited to individuals who received IMV, and a multivariable logistic regression model was created in which dementia was the primary predictor and mortality was the outcome. Of the 13,816,586 hospitalizations of older adults in the United States in 2011, 2,204,506 (16%) with a dementia diagnosis code were identified. Individuals with dementia had statistically significantly lower predicted probability of undergoing IMV (5.7%, 95% confidence interval (CI) = 5.6-5.8% than those without (6.5%, 95% CI = 6.4-6.6%). When the dataset was limited to individuals undergoing IMV, those with dementia were older (mean age 80 vs 76, P < .001) and had a higher combined Gagne comorbidity score (4.4 vs 4.1, P < .001) than those without. In a multivariable model, dementia was associated with greater likelihood of survival to hospital discharge (odds ratio (OR) = 0.79, P < .001). Individuals with dementia also had shorter mean length of stay (12.5 ± 0.2 vs 13.1 ± 0.2, P = .01) and lower cost per hospitalization for survivors ($37,213 vs $44,557, P < .001). Older critically ill adults with dementia undergoing IMV had better in-hospital outcomes than those without dementia. Because a lower adjusted percentage of individuals with dementia underwent IMV, it is likely that patient selection drove outcome differences. These findings suggest that individuals, families, and clinicians are carefully considering prognosis, quality of life, and appropriate use of intensive care unit resources when deciding whether to use IMV in individuals with dementia. © 2016, Copyright the Authors Journal compilation © 2016, The

  1. Assessment of respiratory output in mechanically ventilated patients.

    PubMed

    Laghi, Franco

    2005-06-01

    Mechanically ventilated patients are subject to few pathophysiologic disturbances that have such intuitive importance as abnormal function of the respiratory output. Abnormal function of the respiratory output plays a fundamental role in all aspects of mechanical ventilation: in determining which patients require mechanical ventilation, in determining the interaction between a patient and the ventilator, and in determining when a patient can tolerate discontinuation of mechanical ventilation. Monitoring indexes such as the rate of rise in electrical activity of the diaphragm, Po.1, (dP/dt)max, and Pmus, has provided insight into the performance of the respiratory centers in critically ill patients, but these methods require considerable refinement. A large body of research on measurements of energy expenditure of the respiratory muscles, such as pressure-time product, and measurements of inspiratory effort, such as the tension-time index, is currently accumulating. Several challenges, however, lay ahead regarding these indices. First, there is the need to identify the correct level of pressure generation and respiratory muscle effort that should be attained in the day-to-day management of mechanically ventilated patients. The correct titration of ventilator setting should not cause iatrogenic muscle damage because the support is excessive or insufficient. One of the challenges in reaching this goal is that for the same patient, different underlying pathologic conditions (eg, sepsis or ventilator-associated muscle injury) may require different levels of support. Second, many of the measurements of pressure generation and effort have been confined to the research laboratory. Modifications of the technology to achieve accurate measurements in the intensive care unit-outside of the research laboratory--are needed. To facilitate individual titration of ventilator settings, the new technologies must provide easier access to quantification of drive, pressure output, and

  2. 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.

  3. Successful Prolonged Mechanical CPR in a Severely Poisoned Hypothermic Patient: A Case Report.

    PubMed

    Piacentini, Alberto; Volonte', Maurizio; Rigamonti, Marcello; Guastella, Elisa; Landriscina, Mario

    2012-01-01

    Mechanical cardiopulmonary resuscitation (m-CPR) devices are an alternative to manual CPR, but their efficacy has been subject to debate. We present a case of a patient with full-neurologic recovery after prolonged m-CPR. The patient presented with severe hypothermia (internal temperature 24°C) and poisoning (sedatives/hypnotics). Hepatic perfusion and metabolism are considered keys to restore spontaneous circulation. During this period no problems related to the device or patient positioning were encountered. Delivery of high-quality CPR and prolonged resuscitation were achieved. We confirm that ventilations asynchronous with chest compressions can be a problem. Reduction in chest measurements can hamper lung ventilation. A synchronous mode of manual ventilation (30 : 2) seems to be the best solution. The patient had an initial period of manual CPR. No damage to any organ or structure was noted. This case is of further interest because our EMS helicopters can fly 24 hours a day and m-CPR devices could play an important role as a "bridge" in patients when active rewarming by cardiopulmonary bypass is indicated (CPB).

  4. Sedation in mechanically ventilated patients—time to stay awake?

    PubMed Central

    Moreira, Fabio Tanzillo

    2016-01-01

    On June, 2016, Klompas and colleagues published an article in the Chest entitled “Associations between different sedatives and ventilator-associated events, length of stay, and mortality in patients who were mechanically ventilated”, which investigated the effects of different sedatives on ventilator-associated events (VAEs), length of stay, and mortality in patients who were mechanically ventilated. This study used data of over 9,603 patients in order to investigate patients over the age of 18 who underwent mechanical ventilation for more than 3 days over a 7-year period in a large academic medical center. The investigators found that propofol and dexmedetomidine were associated with less time to extubation compared with benzodiazepines, but dexmedetomidine was also associated with less time to extubation vs. propofol. This study raises important questions about the sedation of critically ill patients. PMID:27826584

  5. Issues in weaning from mechanical ventilation: literature review.

    PubMed

    Rose, Louise; Nelson, Sioban

    2006-04-01

    The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation. Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process. In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations. Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level. Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.

  6. 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.

  7. Synchronized mechanical ventilation for respiratory support in newborn infants.

    PubMed

    Greenough, Anne; Rossor, Thomas E; Sundaresan, Adesh; Murthy, Vadivelam; Milner, Anthony D

    2016-09-01

    During synchronised mechanical ventilation, positive airway pressure and spontaneous inspiration coincide. If synchronous ventilation is provoked, adequate gas exchange should be achieved at lower peak airway pressures, potentially reducing baro/volutrauma, air leak and bronchopulmonary dysplasia. Synchronous ventilation can potentially be achieved by manipulation of rate and inspiratory time during conventional ventilation and employment of patient-triggered ventilation. To compare the efficacy of:(i) synchronised mechanical ventilation, delivered as high-frequency positive pressure ventilation (HFPPV) or patient-triggered ventilation (assist control ventilation (ACV) and synchronous intermittent mandatory ventilation (SIMV)), with conventional ventilation or high-frequency oscillation (HFO);(ii) different types of triggered ventilation (ACV, SIMV, pressure-regulated volume control ventilation (PRVCV), SIMV with pressure support (PS) and pressure support ventilation (PSV)). We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 5), MEDLINE via PubMed (1966 to June 5 2016), EMBASE (1980 to June 5 2016), and CINAHL (1982 to June 5 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised clinical trials comparing synchronised ventilation delivered as HFPPV to CMV, or ACV/SIMV to CMV or HFO in neonates. Randomised trials comparing different triggered ventilation modes (ACV, SIMV, SIMV plus PS, PRVCV and PSV) in neonates. Data were collected regarding clinical outcomes including mortality, air leaks (pneumothorax or pulmonary interstitial emphysema (PIE)), severe intraventricular haemorrhage (grades 3 and 4), bronchopulmonary dysplasia (BPD) (oxygen dependency beyond 28 days), moderate/severe BPD (oxygen

  8. Synchronized mechanical ventilation for respiratory support in newborn infants.

    PubMed

    Greenough, Anne; Murthy, Vadivelam; Milner, Anthony D; Rossor, Thomas E; Sundaresan, Adesh

    2016-08-19

    During synchronised mechanical ventilation, positive airway pressure and spontaneous inspiration coincide. If synchronous ventilation is provoked, adequate gas exchange should be achieved at lower peak airway pressures, potentially reducing baro/volutrauma, air leak and bronchopulmonary dysplasia. Synchronous ventilation can potentially be achieved by manipulation of rate and inspiratory time during conventional ventilation and employment of patient-triggered ventilation. To compare the efficacy of:(i) synchronised mechanical ventilation, delivered as high-frequency positive pressure ventilation (HFPPV) or patient-triggered ventilation (assist control ventilation (ACV) and synchronous intermittent mandatory ventilation (SIMV)), with conventional ventilation or high-frequency oscillation (HFO);(ii) different types of triggered ventilation (ACV, SIMV, pressure-regulated volume control ventilation (PRVCV), SIMV with pressure support (PS) and pressure support ventilation (PSV)). We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 5), MEDLINE via PubMed (1966 to June 5 2016), EMBASE (1980 to June 5 2016), and CINAHL (1982 to June 5 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised clinical trials comparing synchronised ventilation delivered as HFPPV to CMV, or ACV/SIMV to CMV or HFO in neonates. Randomised trials comparing different triggered ventilation modes (ACV, SIMV, SIMV plus PS, PRVCV and PSV) in neonates. Data were collected regarding clinical outcomes including mortality, air leaks (pneumothorax or pulmonary interstitial emphysema (PIE)), severe intraventricular haemorrhage (grades 3 and 4), bronchopulmonary dysplasia (BPD) (oxygen dependency beyond 28 days), moderate/severe BPD (oxygen

  9. Leakage estimation using Kalman filtering in noninvasive mechanical ventilation.

    PubMed

    Rodrigues, G G; Freitas, U S; Bounoiare, D; Aguirre, L A; Letellier, C

    2013-05-01

    Noninvasive mechanical ventilation is today often used to assist patient with chronic respiratory failure. One of the main reasons evoked to explain asynchrony events, discomfort, unwillingness to be treated, etc., is the occurrence of nonintentional leaks in the ventilation circuit, which are difficult to account for because they are not measured. This paper describes a solution to the problem of variable leakage estimation based on a Kalman filter driven by airflow and the pressure signals, both of which are available in the ventilation circuit. The filter was validated by showing that based on the attained leakage estimates, practically all the untriggered cycles can be explained.

  10. 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.

  11. Noninvasive mechanical ventilation in immediate postoperative cardiac surgery patients.

    PubMed

    Mazullo Filho, João Batista Raposo; Bonfim, Vânia Jandira Gomes; Aquim, Esperidião Elias

    2010-12-01

    Noninvasive ventilation is routine in acute respiratory failure patients; nevertheless, the literature is controversial for its use in cardiac surgery postoperative period. To evaluate the effectiveness of preventive noninvasive ventilation in the immediate postoperative period of cardiac surgery, monitoring its impact until the sixth day of hospitalization. This was a controlled study, where patients in immediate postoperative period of cardiac surgery were randomized into two groups: control (G1) and investigational (G2) which received noninvasive ventilation set on pressure support mode and positive end expiratory pressure, for 2 hours following extubation. Were evaluated ventilatory, hemodynamical and oxygenation variables both immediately after extubation and after noninvasive ventilation in G2. Thirty-two patients completed the study, 18 in G1 and 14 in G2. The mean age was 61±16.23 years for G1 and for G2 61.5 ± 9.4 years. Of the initial twenty-seven patients in G1, nine patients (33.3%) were excluded due to invasive ventilation requirements, and three patients (11.11%) had to go back to invasive mechanical ventilation. None of the 14 G2 patients was reintubated. Patients undergoing early ventilatory support showed better results in the assessments throughout the hospitalization time. Noninvasive post-cardiac surgery ventilation was proven effective, as demonstrated by increased vital capacity, decreased respiratory rate, prevention of post-extubation acute respiratory failure and reduced reintubation rates.

  12. Clinical review: Respiratory mechanics in spontaneous and assisted ventilation

    PubMed Central

    Grinnan, Daniel C; Truwit, Jonathon Dean

    2005-01-01

    Pulmonary disease changes the physiology of the lungs, which manifests as changes in respiratory mechanics. Therefore, measurement of respiratory mechanics allows a clinician to monitor closely the course of pulmonary disease. Here we review the principles of respiratory mechanics and their clinical applications. These principles include compliance, elastance, resistance, impedance, flow, and work of breathing. We discuss these principles in normal conditions and in disease states. As the severity of pulmonary disease increases, mechanical ventilation can become necessary. We discuss the use of pressure–volume curves in assisting with poorly compliant lungs while on mechanical ventilation. In addition, we discuss physiologic parameters that assist with ventilator weaning as the disease process abates. PMID:16277736

  13. Cardiac output estimation using pulmonary mechanics in mechanically ventilated patients

    PubMed Central

    2010-01-01

    The application of positive end expiratory pressure (PEEP) in mechanically ventilated (MV) patients with acute respiratory distress syndrome (ARDS) decreases cardiac output (CO). Accurate measurement of CO is highly invasive and is not ideal for all MV critically ill patients. However, the link between the PEEP used in MV, and CO provides an opportunity to assess CO via MV therapy and other existing measurements, creating a CO measure without further invasiveness. This paper examines combining models of diffusion resistance and lung mechanics, to help predict CO changes due to PEEP. The CO estimator uses an initial measurement of pulmonary shunt, and estimations of shunt changes due to PEEP to predict CO at different levels of PEEP. Inputs to the cardiac model are the PV loops from the ventilator, as well as the oxygen saturation values using known respiratory inspired oxygen content. The outputs are estimates of pulmonary shunt and CO changes due to changes in applied PEEP. Data from two published studies are used to assess and initially validate this model. The model shows the effect on oxygenation due to decreased CO and decreased shunt, resulting from increased PEEP. It concludes that there is a trade off on oxygenation parameters. More clinically importantly, the model also examines how the rate of CO drop with increased PEEP can be used as a method to determine optimal PEEP, which may be used to optimise MV therapy with respect to the gas exchange achieved, as well as accounting for the impact on the cardiovascular system and its management. PMID:21108836

  14. Fluid balance and length of mechanical ventilation in children admitted to a single Pediatric Intensive Care Unit.

    PubMed

    Vidal, Solange; Pérez, Augusto; Eulmesekian, Pablo

    2016-08-01

    Associations between cumulative fluid balance and a prolonged duration of assisted mechanical ventilation have been described in adults. The aim of this study was to evaluate whether fluid balance in the first 48 hours of assisted mechanical ventilation initiation was associated with a prolonged duration of this process among children in the Pediatric Intensive Care Unit (PICU). Retrospective cohort of patients in the PICU o, Hospital Italiano de Buenos Aires, between 1/1/2010 and 6/30/2012. Balance was calculated in percentage of body weight; prolonged mechanical ventilation was defined as >7 days, and confounders were registered. Univariate and multivariate analyses were performed. Two hundred and forty-nine patients were mechanically ventilated for over 48 hours; 163 were included in the study. Balance during the first 48 hours of mechanical ventilation was 5.7% ± 5.86; 82 patients (50.3%) were on mechanical ventilation for more than 7 days. Age 〈 4 years old (OR 3.21, 95% CI 1.38-7.48, p 0.007), respiratory disease (OR 4.94, 95% CI 1.51-16.10, p 0.008), septic shock (OR 4.66, 95% CI 1.10-19.65, p 0.036), Pediatric Logistic Organ Dysfunction (PELOD) 〉 10 (OR 2.44, 95% CI 1.234.85, p 0.011), and positive balance 〉 13% (OR 4.02, 95% CI 1.08-15.02, p 0.038) were associated with prolonged mechanical ventilation. The multivariate model resulted in an OR 2.58, 95% CI: 1.17-5.58, p= 0.018 for PELOD 〉 10, and an OR 3.7, 95% CI: 0.91-14.94, p= 0.066 for positive balance 〉 13%. Regarding prolonged mechanical ventilation, the multivariate model showed an independent association with organ dysfunction (PELOD 〉 10) and a trend towards an association with positive balance 〉 13%. Sociedad Argentina de Pediatría.

  15. Complications in mechanically ventilated patients of Guillain-Barre syndrome and their prognostic value.

    PubMed

    Netto, Archana Becket; Taly, Arun B; Kulkarni, Girish B; Uma Maheshwara Rao, G S; Rao, Shivaji

    2017-01-01

    The spectrum of various complications in critically ill Guillain-Barre syndrome (GBS) and its effect on the prognosis is lacking in literature. This study aimed at enumerating the complications in such a cohort and their significance in the prognosis and mortality. Retrospective case record analysis of all consecutive mechanically ventilated patients of GBS in neurology Intensive Care Unit (ICU) of a tertiary care institute for 10 years was done. Demographic, laboratory, and treatment details and outcome parameters were recorded. Among the 173 patients were 118 men and 55 women (2.1:1), aged 1-84 years. The average number of ICU complications per patient was 6.8 ± 1.8 (median = 7, range = 1-12). The most common complication was tracheobronchitis (128). Other pulmonary complications were found in 36 patients. The next was metabolic hyponatremia (115) hypokalemia (67), hypocalcemia (13), stress hyperglycemia (10), hyperkalemia (8), hypernatremia (9). Sepsis (40), UTI (47), dysautonomia (27), hypoalbuminemia (76), anemia (75), seizures (8), paralytic ileus (5), bleeding (4), anoxic encephalopathy (3), organ failures (12), deep vein thrombosis (7), and drug rashes (1) were also noted. The complications, considered significant in causing death, Hughes scale ≤ 3 at discharge, prolonged mechanical ventilation (>21 days) and hospitalization (>36 days) were pneumonia, hyponatremia, hypokalemia, urinary infection, tracheobronchial infections, hypoalbuminemia, sepsis, anemia dysautonomia. Active monitoring and appropriate and early intervention by the clinician will improve the quality of life of these patients and reduce the cost of prolonged mechanical ventilation and ICU stay.

  16. Mechanical Power and Development of Ventilator-induced Lung Injury.

    PubMed

    Cressoni, Massimo; Gotti, Miriam; Chiurazzi, Chiara; Massari, Dario; Algieri, Ilaria; Amini, Martina; Cammaroto, Antonio; Brioni, Matteo; Montaruli, Claudia; Nikolla, Klodiana; Guanziroli, Mariateresa; Dondossola, Daniele; Gatti, Stefano; Valerio, Vincenza; Vergani, Giordano Luca; Pugni, Paola; Cadringher, Paolo; Gagliano, Nicoletta; Gattinoni, Luciano

    2016-05-01

    The ventilator works mechanically on the lung parenchyma. The authors set out to obtain the proof of concept that ventilator-induced lung injury (VILI) depends on the mechanical power applied to the lung. Mechanical power was defined as the function of transpulmonary pressure, tidal volume (TV), and respiratory rate. Three piglets were ventilated with a mechanical power known to be lethal (TV, 38 ml/kg; plateau pressure, 27 cm H2O; and respiratory rate, 15 breaths/min). Other groups (three piglets each) were ventilated with the same TV per kilogram and transpulmonary pressure but at the respiratory rates of 12, 9, 6, and 3 breaths/min. The authors identified a mechanical power threshold for VILI and did nine additional experiments at the respiratory rate of 35 breaths/min and mechanical power below (TV 11 ml/kg) and above (TV 22 ml/kg) the threshold. In the 15 experiments to detect the threshold for VILI, up to a mechanical power of approximately 12 J/min (respiratory rate, 9 breaths/min), the computed tomography scans showed mostly isolated densities, whereas at the mechanical power above approximately 12 J/min, all piglets developed whole-lung edema. In the nine confirmatory experiments, the five piglets ventilated above the power threshold developed VILI, but the four piglets ventilated below did not. By grouping all 24 piglets, the authors found a significant relationship between the mechanical power applied to the lung and the increase in lung weight (r = 0.41, P = 0.001) and lung elastance (r = 0.33, P < 0.01) and decrease in PaO2/FIO2 (r = 0.40, P < 0.001) at the end of the study. In piglets, VILI develops if a mechanical power threshold is exceeded.

  17. Mechanical ventilation reduces rat diaphragm blood flow and impairs O2 delivery and uptake

    PubMed Central

    Davis, Robert T.; Bruells, Christian S.; Stabley, John N.; McCullough, Danielle J.; Powers, Scott K.; Behnke, Bradley J.

    2012-01-01

    Objectives Although mechanical ventilation (MV) is a life-saving intervention in patients suffering from respiratory failure, prolonged MV is often associated with numerous complications including problematic weaning. In contracting skeletal muscle, inadequate O2 supply can limit oxidative phosphorylation resulting in muscular fatigue. However, whether prolonged MV results in decreased diaphragmatic blood and induces an O2 supply-demand imbalance in the diaphragm remains unknown. Design We tested the hypothesis that prolonged controlled MV results in a time-dependent reduction in rat diaphragmatic blood flow and microvascular PO2 and that prolonged MV would diminish the diaphragm’s ability to increase blood flow in response to muscular contractions. Measurements and Main Results Compared to 30 min of MV, 6 hrs of MV resulted in a 75% reduction in diaphragm blood flow (via radiolabeled microspheres), which did not occur in the intercostal muscle or high-oxidative hindlimb muscle (e.g., soleus). There was also a time-dependent decline in diaphragm microvascular PO2 (via phosphorescence quenching). Further, when contrasted to 30 min of MV, 6 hrs of MV significantly compromised the diaphragm’s ability to increase blood flow during electrically-induced contractions which resulted in a ~80% reduction in diaphragm O2 uptake. In contrast, 6 hrs of spontaneous breathing in anesthetized animals did not alter diaphragm blood flow or the ability to augment flow during electrically-induced contractions. Conclusions These new and important findings reveal that prolonged MV results in a time-dependent decrease in the ability of the diaphragm to augment blood flow to match O2 demand in response to contractile activity and could be a key contributing factor to difficult weaning. Although additional experiments are required to confirm, it is tempting to speculate that this ventilator-induced decline in diaphragmatic oxygenation could promote a hypoxia-induced generation of

  18. Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients.

    PubMed

    Pingleton, S K; Hadzima, S K

    1983-01-01

    The incidence of upper gastrointestinal (GI) bleeding in mechanically ventilated ICU patients receiving enteral alimentation was reviewed and compared to bleeding occurring in ventilated patients receiving prophylactic antacids or cimetidine. Of 250 patients admitted to our ICU during a 1-yr time period, 43 ventilated patients were studied. Patients in each group were comparable with respect to age, respiratory diagnosis, number of GI hemorrhage risk factors, and number of ventilator, ICU, and hospital days. Twenty-one patients had evidence of GI bleeding. Fourteen of 20 patients receiving antacids and 7 of 9 patients receiving cimetidine had evidence of GI bleeding. No bleeding occurred in 14 patients receiving enteral alimentation. Complications of enteral alimentation were few and none required discontinuation of enteral alimentation. Our preliminary data suggest the role of enteral alimentation in critically ill patients may include not only protection against malnutrition but also protection against GI bleeding.

  19. Outcome of mechanically ventilated patients who require a tracheostomy.

    PubMed

    Frutos-Vivar, Fernando; Esteban, Andrés; Apezteguía, Carlos; Anzueto, Antonio; Nightingale, Peter; González, Marco; Soto, Luis; Rodrigo, Carlos; Raad, Jean; David, Cide M; Matamis, Dimitros; D' Empaire, Gabriel

    2005-02-01

    To estimate the prevalence of, the risk factors associated with, and the outcome of tracheostomy in a heterogeneous population of mechanically ventilated patients. Prospective, observational cohort study. A total of 361 intensive care units from 12 countries. A cohort of 5,081 patients mechanically ventilated for >12 hrs. None. A total of 546 patients (10.7%) had a tracheostomy during their stay in the intensive care unit. Tracheostomy was performed at a median time of 12 days (interquartile range, 7-17) from the beginning of mechanical ventilation. Variables associated with the performance of tracheostomy were duration of mechanical ventilation, need for reintubation, and neurologic disease as the primary reason of mechanical ventilation. The intensive care unit stay of patients with or without tracheostomy was a median of 21 days (interquartile range, 12-32) vs. 7 days (interquartile range, 4-12; p < .001), respectively, and the hospital stay was a median 36 days (interquartile range, 23-53) vs. 15 days (interquartile range, 8-26; p < .001), respectively. Adjusting by other variables, tracheostomy was independently related with survival in the intensive care unit (odds ratio, 2.22; 95% confidence interval, 1.72-2.86). Mortality in the hospital was similar in both groups (39% vs. 40%, p = .65). Tracheostomy is a common surgical procedure in the intensive care unit that is associated with a lower mortality in the unit but with a longer stay and a similar mortality in the hospital than in patients without tracheostomy.

  20. 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

  1. 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

  2. [Bronchoalveolar lavage with diluted porcine surfactant for alveolar debris removal in newborns treated with mechanical ventilation].

    PubMed

    Lista, G; Castoldi, F; Azzali, A; Compagnoni, G

    2000-01-01

    Lung debris in respiratory distress syndrome (RDS) and meconium aspiration syndrome (MAS) contribute to deteriorate pulmonary function. Surfactant lavage, also with minimal quantity of diluted surfactant, is an effective method for treatment of severe MAS and seems to be useful also in course of RDS evolving to chronic lung disease (CLD), by improving lung mechanics. Authors report a clinical study in which tracheobronchial lavage with surfactant (15 ml/Kg of diluted porcine surfactant) improved significantly lung function in 3 patients with RDS in prolonged mechanical ventilation and in 2 patients with MAS.

  3. 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

  4. Mitochondrial-targeted antioxidants protect against mechanical ventilation-induced diaphragm weakness

    PubMed Central

    Powers, Scott K.; Hudson, Matthew B.; Nelson, W. Bradley; Talbert, Erin E.; Min, Kisuk; Szeto, Hazel H.; Kavazis, Andreas N.; Smuder, Ashley J.

    2015-01-01

    BACKGROUND Mechanical ventilation (MV) is a life-saving intervention used to provide adequate pulmonary ventilation in patients suffering from respiratory failure. However, prolonged MV is associated with significant diaphragmatic weakness resulting from both myofiber atrophy and contractile dysfunction. Although several signaling pathways contribute to diaphragm weakness during MV, it is established that oxidative stress is required for diaphragmatic weakness to occur. Therefore, identifying the site(s) of MV-induced reactive oxygen species (ROS) production in the diaphragm is important. OBJECTIVE These experiments tested the hypothesis that elevated mitochondrial ROS emission is required for MV-induced oxidative stress, atrophy, and contractile dysfunction in the diaphragm. DESIGN Cause and effect was determined by preventing MV-induced mitochondrial ROS emission in the diaphragm of rats using a novel mitochondrial-targeted antioxidant (SS-31). MEASUREMENTS AND MAIN RESULTS Compared to mechanically ventilated animals treated with saline, animals treated with SS-31 were protected against MV-induced mitochondrial dysfunction, oxidative stress, and protease activation in the diaphragm. Importantly, treatment of animals with the mitochondrial antioxidant also protected the diaphragm against MV-induced myofiber atrophy and contractile dysfunction. CONCLUSIONS These results reveal that prevention of MV-induced increases in diaphragmatic mitochondrial ROS emission protects the diaphragm MV-induced diaphragmatic weakness. This important new finding indicates that mitochondria are a primary source of ROS production in the diaphragm during prolonged MV. These results could lead to the development of a therapeutic intervention to impede MV-induced diaphragmatic weakness. PMID:21460706

  5. Nursing care of the mechanically ventilated patient in ITU: 1.

    PubMed

    Ashurst, S

    The mechanically ventilated patient often represents the ultimate in vulnerability and demands the highest standards of nursing care. Not only may the patient be unconscious but also the artificial airway is an unnatural invasion of the most innate physiological mechanism--breathing, and the nurse must safeguard this during all aspects of care. Nursing these patients is immensely satisfying and varied. It ranges from caring for the patient's activities of daily living to carrying out the highly technical and invasive monitoring and interventions which require specialist knowledge and skills. This article, the first in a two-part series, covers the types of ventilation, suction therapy, oral and eye care, elimination, body position, physiotherapy and the physiological effects of mechanical ventilation.

  6. Links between the mechanics of ventilation and spine stability.

    PubMed

    Wang, Simon; McGill, Stuart M

    2008-05-01

    Spine stability is ensured through isometric coactivation of the torso muscles; however, these same muscles are used cyclically to assist ventilation. Our objective was to investigate this apparent paradoxical role (isometric contraction for stability or rhythmic contraction for ventilation) of some selected torso muscles that are involved in both ventilation and support of the spine. Eight, asymptomatic, male subjects provided data on low back moments, motion, muscle activation, and hand force. These data were input to an anatomically detailed, biologically driven model from which spine load and a lumbar spine stability index was obtained. Results revealed that subjects entrained their torso stabilization muscles to breathe during demanding ventilation tasks. Increases in lung volume and back extensor muscle activation coincided with increases in spine stability, whereas declines in spine stability were observed during periods of low lung inflation volume and simultaneously low levels of torso muscle activation. As a case study, aberrant ventilation motor patterns (poor muscle entrainment), seen in one subject, compromised spine stability. Those interested in rehabilitation of patients with lung compromise and concomitant back troubles would be assisted with knowledge of the mechanical links between ventilation during tasks that impose spine loading.

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

    PubMed

    López Sanchez, M

    2017-02-08

    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 CO2 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.

  8. 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.

  9. 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

  10. 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

  11. Brazilian recommendations of mechanical ventilation 2013. Part I.

    PubMed

    Barbas, Carmen Sílvia Valente; Isola, 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; Carvalho, Carlos Roberto Ribeiro de; Toufen Júnior, 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; Matos, Gustavo Faissol Janot de; 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; Jesus, Rodrigo Francisco de; 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 Pneumonia 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.

  12. Brazilian recommendations of mechanical ventilation 2013. Part I.

    PubMed

    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.

  13. Brazilian recommendations of mechanical ventilation 2013. Part 2.

    PubMed

    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.

  14. 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

  15. 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

  16. Lung mechanics in the TIMP3 null mouse and its response to mechanical ventilation.

    PubMed

    Martin, Erica L; Truscott, Emily A; Bailey, Timothy C; Leco, Kevin J; McCaig, Lynda A; Lewis, James F; Veldhuizen, Ruud A W

    2007-03-01

    Tissue inhibitor of metalloproteinase-3 (TIMP3) null mice develop emphysema-like airspace enlargement due to an enzymatic imbalance. This study investigates how these abnormalities alter lung mechanics and the response to 2 different mechanical ventilation strategies. Phenotypically, TIMP3 null mice had increased compliance, and decreased resistance, tissue damping, and tissue elastance over wild-type controls. Decreased compliance and increased resistance were observed following the injurious ventilation strategy; however, the TIMP3 null response to both ventilation strategies was similar to wild-type mice. In conclusion, TIMP3 null mice have significant alterations in lung mechanics; however, this does not affect their response to ventilation.

  17. 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 (VT). 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. VT 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 profiles

  18. ICU Occupancy and mechanical ventilator use in the United States

    PubMed Central

    Wunsch, Hannah; Wagner, Jason; Herlim, Maximilian; Chong, David; Kramer, Andrew; Halpern, Scott D.

    2013-01-01

    Objectives Detailed data on occupancy and use of mechanical ventilators in United States intensive care units (ICU) over time and across unit types, are lacking. We sought to describe the hourly bed occupancy and use of ventilators in US ICUs to improve future planning of both the routine and disaster provision of intensive care. Design Retrospective cohort study. We calculated mean hourly bed occupancy in each ICU and hourly bed occupancy for patients on mechanical ventilators. We assessed trends in overall occupancy over the three years. We also assessed occupancy and mechanical ventilation rates across different types and sizes of ICUs. Setting 97 US ICUs participating in Project IMPACT from 2005–07. Patients 226,942 consecutive admissions to ICUs. Interventions None. Measurements and Main Results Over the three years studied, total ICU occupancy ranged from 57.4% to 82.1% and the number of beds filled with mechanically ventilated patients ranged from 20.7% to 38.9%. There was no change in occupancy across years and no increase in occupancy during influenza seasons. Mean hourly occupancy across ICUs was 68.2% SD ± 21.3, and was substantially higher in ICUs with fewer beds (mean 75.8% (± 16.5) for 5–14 beds versus 60.9% (± 22.1) for 20+ beds, P = 0.001), and in academic hospitals (78.7% (± 15.9) versus 65.3% (± 21.3) for community not-for profit hospitals, P < 0.001). More than half (53.6%) of ICUs had 4+ beds available more than half the time. The mean percentage of ICU patients receiving mechanical ventilation in any given hour was 39.5% (± 15.2), and a mean of 29.0% (± 15.9) of ICU beds were filled with a patient on a ventilator. Conclusions Occupancy of US ICUs was stable over time, but there is uneven distribution across different types and sizes of units. Only three out of ten beds were filled at any time with mechanically ventilated patients, suggesting substantial surge capacity throughout the system to care for acutely critically ill patients

  19. Best Practices for Managing Pain, Sedation, and Delirium in the Mechanically Ventilated Patient.

    PubMed

    Garrett, Kitty M

    2016-12-01

    Nursing management of pain, agitation, and delirium in mechanically ventilated patients is a challenge in critical care. Oversedation can lead to delayed extubation, prolonged ventilator days, unnecessary neurologic testing, and complications such as weakness and delirium. Undersedation can lead to self-extubation, invasive line removal, unnecessary patient distress, and injury to self or others. Acquiring an optimal level of sedation requires the bedside nurse to be more vigilant than ever with patient assessment and medication titration. This article provides a historical perspective of the management of pain, agitation, and delirium, and disseminates information contained in revised Society for Critical Care Medicine Clinical Practice Guidelines (January 2013) to promote their implementation in day-to-day nursing care.

  20. Lung hyperinflation by mechanical ventilation versus isolated tracheal aspiration in the bronchial hygiene of patients undergoing mechanical ventilation

    PubMed Central

    Assmann, Crisiela Brum; Vieira, Paulo José Cardoso; Kutchak, Fernanda; Rieder, Marcelo de Mello; Forgiarini, Soraia Genebra Ibrahim; Forgiarini Junior, Luiz Alberto

    2016-01-01

    Objective To determine the efficacy of lung hyperinflation maneuvers via a mechanical ventilator compared to isolated tracheal aspiration for removing secretions, normalizing hemodynamics and improving lung mechanics in patients on mechanical ventilation. Methods This was a randomized crossover clinical trial including patients admitted to the intensive care unit and on mechanical ventilation for more than 48 hours. Patients were randomized to receive either isolated tracheal aspiration (Control Group) or lung hyperinflation by mechanical ventilator (MVH Group). Hemodynamic and mechanical respiratory parameters were measured along with the amount of aspirated secretions. Results A total of 50 patients were included. The mean age of the patients was 44.7 ± 21.6 years, and 31 were male. Compared to the Control Group, the MVH Group showed greater aspirated secretion amount (3.9g versus 6.4g, p = 0.0001), variation in mean dynamic compliance (-1.3 ± 2.3 versus -2.9 ± 2.3; p = 0.008), and expired tidal volume (-0.7 ± 0.0 versus -54.1 ± 38.8, p = 0.0001) as well as a significant decrease in peak inspiratory pressure (0.2 ± 0.1 versus 2.5 ± 0.1; p = 0.001). Conclusion In the studied sample, the MVH technique led to a greater amount of aspirated secretions, significant increases in dynamic compliance and expired tidal volume and a significant reduction in peak inspiratory pressure. PMID:27096673

  1. Spontaneous gasping during cardiopulmonary resuscitation without mechanical ventilation.

    PubMed

    Noc, M; Weil, M H; Sun, S; Tang, W; Bisera, J

    1994-09-01

    Spontaneous gasping is frequently observed during cardiac arrest, especially when mechanical ventilation is withheld during precordial compression. We related spontaneous gasping to pulmonary gas exchange and cardiac resuscitability in a rodent model of cardiac arrest. Ventricular fibrillation was electrically induced in 15 Sprague-Dawley rats. After 4 min untreated ventricular fibrillation, precordial compression was initiated. Coronary perfusion pressure was maintained between 25 and 30 mm Hg. Oxygen was supplied at the tracheal tube port coincident with start of precordial compression in 10 animals. Five additional control animals were identically treated except they were mechanically ventilated coincident with start of precordial compression. After 6 min precordial compression, defibrillation was attempted and five of 10 nonventilated animals, and all control animals, were resuscitated by direct current countershock. In the successfully resuscitated, nonventilated animals, the frequency of spontaneous gasping during precordial compression progressively increased to an average of 19 gasps/min but it was < 6 gasps/min in nonresuscitated animals. More frequent gasping was associated with correspondingly greater arterial PO2 (110 versus 51 mm Hg, p < 0.01) and lesser PCO2 (55 versus 91 mm Hg, p < 0.01). In control animals, no spontaneous gasping was observed during precordial compression. Arterial PO2 and PCO2 of mechanically ventilated animals was more like that of spontaneously gasping rats. According, the frequency of spontaneous gasping in absence of mechanical ventilation is predictive of cardiac resuscitation success and associated with improved arterial oxygenation and CO2 removal.

  2. Lemierre's Syndrome Associated with Mechanical Ventilation and Profound Deafness

    PubMed Central

    2017-01-01

    Lemierre's syndrome is a rare disorder that is characterized by anaerobic organisms inducing a thrombophlebitis of the internal jugular vein (IJV) following a course of oropharyngeal infection. It often occurs in young and healthy patients. Clinicians continuously misinterpret early symptoms until infection disseminates systematically and life-threatening sepsis transpires. We report the case of a 58-year-old female developing Lemierre's syndrome accompanied by invasive ventilation support and a profound deafness requiring the implementation of a cochlear implant. This is one of two reported cases of Lemierre's syndrome associated with mechanical ventilation support and the only case associated with a cochlear implant. PMID:28331642

  3. 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.

  4. Helium-oxygen reduces the production of carbon dioxide during weaning from mechanical ventilation

    PubMed Central

    2010-01-01

    Background Prolonged weaning from mechanical ventilation has a major impact on ICU bed occupancy and patient outcome, and has significant cost implications. There is evidence in patients around the period of extubation that helium-oxygen leads to a reduction in the work of breathing. Therefore breathing helium-oxygen during weaning may be a useful adjunct to facilitate weaning. We hypothesised that breathing helium-oxygen would reduce carbon dioxide production during the weaning phase of mechanical ventilation. Materials/patients and methods We performed a prospective randomised controlled single blinded cross-over trial on 19 adult intensive care patients without significant airways disease who fulfilled criteria for weaning with CPAP. Patients were randomised to helium-oxygen and air-oxygen delivered during a 2 hour period of CPAP ventilation. Carbon dioxide production (VCO2) was measured using a near patient main stream infrared carbon dioxide sensor and fixed orifice pneumotachograph. Results Compared to air-oxygen, helium-oxygen significantly decreased VCO2 production at the end of the 2 hour period of CPAP ventilation; there was a mean difference in CO2 production of 48.9 ml/min (95% CI 18.7-79.2 p = 0.003) between the groups. There were no significant differences in other respiratory and haemodynamic parameters. Conclusion This study shows that breathing a helium-oxygen mixture during weaning reduces carbon dioxide production. This physiological study supports the need for a clinical trial of helium-oxygen mixture during the weaning phase of mechanical ventilation with duration of weaning as the primary outcome. Trial registration ISRCTN56470948 PMID:20796307

  5. Helium-oxygen reduces the production of carbon dioxide during weaning from mechanical ventilation.

    PubMed

    Flynn, Gordon; Mandersloot, Gerlinde; Healy, Marie; Saville, Mark; McAuley, Daniel F

    2010-08-26

    Prolonged weaning from mechanical ventilation has a major impact on ICU bed occupancy and patient outcome, and has significant cost implications.There is evidence in patients around the period of extubation that helium-oxygen leads to a reduction in the work of breathing. Therefore breathing helium-oxygen during weaning may be a useful adjunct to facilitate weaning. We hypothesised that breathing helium-oxygen would reduce carbon dioxide production during the weaning phase of mechanical ventilation. We performed a prospective randomised controlled single blinded cross-over trial on 19 adult intensive care patients without significant airways disease who fulfilled criteria for weaning with CPAP. Patients were randomised to helium-oxygen and air-oxygen delivered during a 2 hour period of CPAP ventilation. Carbon dioxide production (VCO2) was measured using a near patient main stream infrared carbon dioxide sensor and fixed orifice pneumotachograph. Compared to air-oxygen, helium-oxygen significantly decreased VCO2 production at the end of the 2 hour period of CPAP ventilation; there was a mean difference in CO2 production of 48.9 ml/min (95% CI 18.7-79.2 p = 0.003) between the groups. There were no significant differences in other respiratory and haemodynamic parameters. This study shows that breathing a helium-oxygen mixture during weaning reduces carbon dioxide production. This physiological study supports the need for a clinical trial of helium-oxygen mixture during the weaning phase of mechanical ventilation with duration of weaning as the primary outcome. ISRCTN56470948.

  6. Bronchopleural Fistula Resolution with Endobronchial Valve Placement and Liberation from Mechanical Ventilation in Acute Respiratory Distress Syndrome: A Case Series

    PubMed Central

    2017-01-01

    Patients who have acute respiratory distress syndrome (ARDS) with persistent air leaks have worse outcomes. Endobronchial valves (EBV) are frequently deployed after pulmonary resection in noncritically ill patients to reduce and eliminate bronchopleural fistulas (BPFs) with persistent air leak (PAL). Information regarding EBV placement in mechanically ventilated patients with ARDS and high volume persistent air leaks is rare and limited to case reports. We describe three cases where EBV placement facilitated endotracheal extubation in patients with severe respiratory failure on prolonged mechanical ventilation with BPFs. In each case, EBV placement led to immediate resolution of PAL. We believe endobronchial valve placement is a safe method treating persistent air leak with severe respiratory failure and may reduce days on mechanical ventilation. PMID:28367339

  7. 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.

  8. 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.

  9. Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study

    PubMed Central

    Yee, Jennifer; Fuenning, Charles; George, Richard; Hejal, Rana; Haines, Nhi; Dunn, Diane; Gothard, M. David; Ahmed, Rami A.

    2016-01-01

    Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms. Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys. Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions, p < 0.001. A mean increase in self-reported confidence was realized (1.55 to 3.64), p = 0.049. Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management. PMID:26949545

  10. 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

  11. Automated mechanical ventilation: adapting decision making to different disease states.

    PubMed

    Lozano-Zahonero, S; Gottlieb, D; Haberthür, C; Guttmann, J; Möller, K

    2011-03-01

    The purpose of the present study is to introduce a novel methodology for adapting and upgrading decision-making strategies concerning mechanical ventilation with respect to different disease states into our fuzzy-based expert system, AUTOPILOT-BT. The special features are: (1) Extraction of clinical knowledge in analogy to the daily routine. (2) An automated process to obtain the required information and to create fuzzy sets. (3) The controller employs the derived fuzzy rules to achieve the desired ventilation status. For demonstration this study focuses exclusively on the control of arterial CO(2) partial pressure (p(a)CO(2)). Clinical knowledge from 61 anesthesiologists was acquired using a questionnaire from which different disease-specific fuzzy sets were generated to control p(a)CO(2). For both, patients with healthy lung and with acute respiratory distress syndrome (ARDS) the fuzzy sets show different shapes. The fuzzy set "normal", i.e., "target p(a)CO(2) area", ranges from 35 to 39 mmHg for healthy lungs and from 39 to 43 mmHg for ARDS lungs. With the new fuzzy sets our AUTOPILOT-BT reaches the target p(a)CO(2) within maximal three consecutive changes of ventilator settings. Thus, clinical knowledge can be extended, updated, and the resulting mechanical ventilation therapies can be individually adapted, analyzed, and evaluated.

  12. Mechanical ventilation in mass casualty scenarios. Augmenting staff: project XTREME.

    PubMed

    Hanley, Michael E; Bogdan, Gregory M

    2008-02-01

    Disaster preparedness typically includes plans that address the need for surge capacity to manage mass-casualty events. A major concern of disaster preparedness in respiratory therapy focuses on responding to a sudden increase in the volume of patients who require mechanical ventilation. Plans for such disasters must include contingencies to address surge capacity in ventilator inventories and the respiratory therapy staff who will manage the ventilators. Tactics to address these situations include efforts to lower demand by transferring patients to other institutions as well as efforts to augment staffing levels. Staff can be augmented by mobilization of deployable teams of volunteers from outside the region and through exploitation of local resources. The latter includes strategies to recruit local respiratory therapists who are currently in either non-clinical or non-hospital-based positions and policies that optimize existing respiratory therapy resources within an institution by canceling elective surgeries, altering shift structure, and postponing vacations. An alternative approach would employ non-respiratory-therapy staff to assist in the management of patients with respiratory failure. Project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies) is a cross-training program developed to facilitate training of non-respiratory-therapy health professionals to assist in the management of patients who require mechanical ventilation. It includes an interactive digital video disc as well as a competency validation laboratory and is designed to be performed at the time of an emergency. Pilot testing of the program suggests it is effective.

  13. 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.

  14. Analysis of atelectasis, ventilated, and hyperinflated lung during mechanical ventilation by dynamic CT.

    PubMed

    David, Matthias; Karmrodt, Jens; Bletz, Carsten; David, Sybil; Herweling, Annette; Kauczor, Hans-Ulrich; Markstaller, Klaus

    2005-11-01

    To study the dynamics of lung compartments by dynamic CT (dCT) imaging during uninterrupted pressure-controlled ventilation (PCV) and different positive end-expiratory pressure (PEEP) settings in healthy and damaged lungs. Experimental animal investigation. Experimental animal facility of a university department. In seven anesthetized pigs, static inspiratory pressure volume curves were obtained to identify the individual lower inflection point (LIP) before and after saline solution lung lavage. During PCV, PEEP was adjusted 5 millibars (mbar) below the individually determined LIP (LIP - 5), at the LIP, and 5 mbar above the LIP (LIP + 5). Measurements were repeated before and after induction of lung damage. Hemodynamics, arterial and mixed venous blood gases, and dCT imaging in one juxtadiaphragmatic slice (effective temporal resolution of 100 ms) were assessed during uninterrupted PCV in series of three successive respiratory cycles. The mean fractional area (FA) of the hyperinflated lung (FA-H), mean FA of ventilated lung, mean FA of poorly ventilated lung, and mean FA of nonventilated lung (FA-NV), and the change in FA of the whole lung area (DeltaFA) were compared at different PEEP settings. Calculated pulmonary shunt (Qs/Qt) was compared to FA-NV. LIP + 5 decreased the amount of atelectasis (FA-NV) and increased hyperinflation (FA-H) in healthy and injured lungs. Cyclic changes of atelectasis (DeltaFA-NV) and hyperinflation (DeltaFA-H) were observed in both healthy and injured lungs. In the injured but not in the healthy lungs, the amount of cyclic changes of atelectasis and hyperinflation were independent from the adjusted PEEP level. FA-NV correlated with the calculated Qs/Qt, with a slight overestimation (mean +/- SEM, 2.1 +/- 4.1%). dCT imaging allows the following: (1) the quantification of the extent of atelectasis, ventilated, poorly ventilated, and hyperinflated lung parenchyma during ongoing mechanical ventilation; (2) the detection and quantification

  15. Ventilation distribution and chest wall mechanics in microgravity

    NASA Technical Reports Server (NTRS)

    Paiva, M.; Wantier, M.; Verbanck, S.; Engel, L. A.; Prisk, G. K.; Guy, H. J. B.; West, J. B.

    1997-01-01

    The effect of gravity on lung ventilation distribution and the mechanisms of the chest wall were investigated. The following tests were performed with the respiratory monitoring system of the Anthorack, flown onboard Spacelab D2 mission: single breath washout (SBW), multiple breath washout (MBW) and argon rebreathing (ARB). In order to study chest wall mechanisms in microgravity, a respiratory inductive plethysmograph was used. The SBW tests did not reach statistical significance, while the ARB tests showed that gravity independent inhomogeneity of specific ventilation is larger than gravity dependent inhomogeneity. In which concerns the chest wall mechanisms, the analysis on the four astronauts during the normal respirations of the relaxation maneuver showed a 40 percent increase on the abdominal contribution to respiration.

  16. Ventilation distribution and chest wall mechanics in microgravity

    NASA Technical Reports Server (NTRS)

    Paiva, M.; Wantier, M.; Verbanck, S.; Engel, L. A.; Prisk, G. K.; Guy, H. J. B.; West, J. B.

    1997-01-01

    The effect of gravity on lung ventilation distribution and the mechanisms of the chest wall were investigated. The following tests were performed with the respiratory monitoring system of the Anthorack, flown onboard Spacelab D2 mission: single breath washout (SBW), multiple breath washout (MBW) and argon rebreathing (ARB). In order to study chest wall mechanisms in microgravity, a respiratory inductive plethysmograph was used. The SBW tests did not reach statistical significance, while the ARB tests showed that gravity independent inhomogeneity of specific ventilation is larger than gravity dependent inhomogeneity. In which concerns the chest wall mechanisms, the analysis on the four astronauts during the normal respirations of the relaxation maneuver showed a 40 percent increase on the abdominal contribution to respiration.

  17. [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.

  18. A Case of Shunting Postoperative Patent Foramen Ovale Under Mechanical Ventilation Controlled by Different Ventilator Settings.

    PubMed

    Pragliola, Claudio; Di Michele, Sara; Galzerano, Domenico

    2017-06-07

    A 56-year old male with ischemic heart disease and an unremarkable preoperative echocardiogram underwent surgical coronary revascularization. An intraoperative post pump trans-esophageal echocardiogram (TOE) performed while the patient was being ventilated at a positive end expiratory pressure (PEEP) of 8 cm H2O demonstrated a right to left interatrial shunt across a patent foramen ovale (PFO). Whereas oxygen saturation was normal, a reduction of the PEEP to 3 cm H2O led to the complete resolution of the shunt with no change in arterial blood gases. Attempts to increase the PEEP level above 3 mmHg resulted in recurrence of the interatrial shunt. The remaining of the TEE was unremarkable. Mechanical ventilation, particularly with PEEP, causes an increase in intrathoracic pressure. The resulting rise in right atrial pressure, mostly during inspiration, may unveil and pop open an unrecognized PFO, thus provoking a right to left shunt across a seemingly intact interatrial septum. This phenomenon increases the risk of paradoxical embolism and can lead to hypoxemia. The immediate management would be to adjust the ventilatory settings to a lower PEEP level. A routine search for a PFO should be performed in ventilated patients who undergo a TEE.

  19. Ventilation.

    PubMed

    Turner, W A; Bearg, D W; Brennan, T

    1995-01-01

    This chapter begins with an overview of the history of ventilation guidelines, which has led to the guidelines that are in effect today. Of particular interest is the most recent return in the past 5 years to ventilation rates that more closely reflect a mean or average of the range of guidelines that have existed over the past century. OSHA's and the EPA's recognition of the need to operate ventilation systems in buildings in an accountable manner is also of note. Of even more interest is the resurgence of the concept of minimum mixing and once-through ventilation air that has been pursued in parts of Northern Europe for the past 10 years, and in a school that is being designed with this concept in New Hampshire. In addition, the design concept of equipping office buildings with low pressure drop high efficiency particle filtration to remove fine particles from all of the air that is supplied to the occupants is being used increasingly in the U.S. This chapter also presents an overview of the various types of ventilation systems found in homes and commercial office buildings and the common indoor air quality problems that may be associated with them. It also offers an overview of common HVAC evaluation techniques that can be used to determine if a ventilation system is performing in a manner that makes sense for the use of the space and the needs of the occupants. Are the occupants receiving a reasonable supply of outdoor air? Is the air that they receive of reasonable quality? Are obvious pollutants being exhausted? Ventilation systems have become extremely complex and more difficult to run and maintain over the past 40 years. This trend will continue to drive the need for professionally maintained HVAC equipment that is serviced and run by individuals who are accountable for the quality of the air that the system delivers.

  20. Mechanism of Reduced Lung Injury by High Frequency Nasal Ventilation in a Preterm Lamb Model of Neonatal Chronic Lung Disease

    PubMed Central

    Rehan, Virender K.; Fong, Jeanette; Lee, Robert; Sakurai, Reiko; Wang, Zheng-Ming; Dahl, Mar Janna; Lane, Robert H.; Albertine, Kurt H.; Torday, John S.

    2011-01-01

    The mechanism underlying the potentially beneficial effects of the “gentler” modes of ventilation on chronic lung disease (CLD) of the premature infant is not known. We have previously demonstrated that alveolar Parathyroid Hormone-related Protein-Peroxisome Proliferator-Activated Receptorγ (PTHrP-PPARγ) signaling is critically important in alveolar formation, and this signaling pathway is disrupted in hyperoxia- and/or volutrauma-induced neonatal rat lung injury. Whether the same paradigm is also applicable to CLD, resulting from prolonged intermittent mandatory ventilation (IMV), and whether differential effects of the mode of ventilation on the PTHrP-PPARγ signaling pathway explain the potential benefits of the “gentler” modes of ventilation are not known. Using a well-established preterm lamb model of neonatal CLD, we tested the hypothesis that ventilatory support using high-frequency nasal ventilation (HFNV) promotes alveolar PTHrP-PPARγ signaling, whereas IMV inhibits it. Preterm lambs managed by HFNV or IMV for 21 days following preterm delivery at 132-day gestation were studied by Western hybridization and immunofluorescence labeling for key markers of alveolar homeostasis and injury/repair. In lambs managed by IMV, the abundance of key homeostatic alveolar epithelial-mesenchymal markers was reduced, whereas it was significantly increased in the HFNV group, providing a potential molecular mechanism by which “gentler” modes of ventilation reduce neonatal CLD. PMID:21814155

  1. 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.

  2. Effective sample size estimation for a mechanical ventilation trial through Monte-Carlo simulation: Length of mechanical ventilation and Ventilator Free Days.

    PubMed

    Morton, S E; Chiew, Y S; Pretty, C; Moltchanova, E; Scarrott, C; Redmond, D; Shaw, G M; Chase, J G

    2017-02-01

    Randomised control trials have sought to seek to improve mechanical ventilation treatment. However, few trials to date have shown clinical significance. It is hypothesised that aside from effective treatment, the outcome metrics and sample sizes of the trial also affect the significance, and thus impact trial design. In this study, a Monte-Carlo simulation method was developed and used to investigate several outcome metrics of ventilation treatment, including 1) length of mechanical ventilation (LoMV); 2) Ventilator Free Days (VFD); and 3) LoMV-28, a combination of the other metrics. As these metrics have highly skewed distributions, it also investigated the impact of imposing clinically relevant exclusion criteria on study power to enable better design for significance. Data from invasively ventilated patients from a single intensive care unit were used in this analysis to demonstrate the method. Use of LoMV as an outcome metric required 160 patients/arm to reach 80% power with a clinically expected intervention difference of 25% LoMV if clinically relevant exclusion criteria were applied to the cohort, but 400 patients/arm if they were not. However, only 130 patients/arm would be required for the same statistical significance at the same intervention difference if VFD was used. A Monte-Carlo simulation approach using local cohort data combined with objective patient selection criteria can yield better design of ventilation studies to desired power and significance, with fewer patients per arm than traditional trial design methods, which in turn reduces patient risk. Outcome metrics, such as VFD, should be used when a difference in mortality is also expected between the two cohorts. Finally, the non-parametric approach taken is readily generalisable to a range of trial types where outcome data is similarly skewed.

  3. 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

  4. Convexity, Jensen's inequality and benefits of noisy mechanical ventilation.

    PubMed

    Brewster, John F; Graham, M Ruth; Mutch, W Alan C

    2005-09-22

    Mechanical ventilators breathe for you when you cannot or when your lungs are too sick to do their job. Most ventilators monotonously deliver the same-sized breaths, like clockwork; however, healthy people do not breathe this way. This has led to the development of a biologically variable ventilator--one that incorporates noise. There are indications that such a noisy ventilator may be beneficial for patients with very sick lungs. In this paper we use a probabilistic argument, based on Jensen's inequality, to identify the circumstances in which the addition of noise may be beneficial and, equally important, the circumstances in which it may not be beneficial. Using the local convexity of the relationship between airway pressure and tidal volume in the lung, we show that the addition of noise at low volume or low pressure results in higher mean volume (at the same mean pressure) or lower mean pressure (at the same mean volume). The consequence is enhanced gas exchange or less stress on the lungs, both clinically desirable. The argument has implications for other life support devices, such as cardiopulmonary bypass pumps. This paper illustrates the benefits of research that takes place at the interface between mathematics and medicine.

  5. Postoperative Pulmonary Dysfunction and Mechanical Ventilation in Cardiac Surgery

    PubMed Central

    Badenes, Rafael; Lozano, Angels; Belda, F. Javier

    2015-01-01

    Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function. PMID:25705516

  6. Inspiratory muscle training to facilitate weaning from mechanical ventilation: protocol for a systematic review

    PubMed Central

    2011-01-01

    Background In intensive care, weaning is the term used for the process of withdrawal of mechanical ventilation to enable spontaneous breathing to be re-established. Inspiratory muscle weakness and deconditioning are common in patients receiving mechanical ventilation, especially that of prolonged duration. Inspiratory muscle training could limit or reverse these unhelpful sequelae and facilitate more rapid and successful weaning. Methods This review will involve systematic searching of five electronic databases to allow the identification of randomised trials of inspiratory muscle training in intubated and ventilated patients. From these trials, we will extract available data for a list of pre-defined outcomes, including maximal inspiratory pressure, the duration of the weaning period, and hospital length of stay. We will also meta-analyse comparable results where possible, and report a summary of the available pool of evidence. Discussion The data generated by this review will be the most comprehensive answer available to the question of whether inspiratory muscle training is clinically useful in intensive care. As well as informing clinicians in the intensive care setting, it will also inform healthcare managers deciding whether health professionals with skills in respiratory therapy should be made available to provide this sort of intervention. Through the publication of this protocol, readers will ultimately be able to assess whether the review was conducted according to a pre-defined plan. Researchers will be aware that the review is underway, thereby avoid duplication, and be able to use it as a basis for planning similar reviews. PMID:21835031

  7. Expiratory flow limitation in morbidly obese postoperative mechanically ventilated patients.

    PubMed

    Koutsoukou, A; Koulouris, N; Bekos, B; Sotiropoulou, C; Kosmas, E; Papadima, K; Roussos, C

    2004-10-01

    Although obesity promotes tidal expiratory flow limitation (EFL), with concurrent dynamic hyperinflation (DH), intrinsic PEEP (PEEPi) and risk of low lung volume injury, the prevalence and magnitude of EFL, DH and PEEPi have not yet been studied in mechanically ventilated morbidly obese subjects. In 15 postoperative mechanically ventilated morbidly obese subjects, we assessed the prevalence of EFL [using the negative expiratory pressure (NEP) technique], PEEPi, DH, respiratory mechanics, arterial oxygenation and PEEPi inequality index as well as the levels of PEEP required to abolish EFL. In supine position at zero PEEP, 10 patients exhibited EFL with a significantly higher PEEPi and DH and a significantly lower PEEPi inequality index than found in the five non-EFL (NEFL) subjects. Impaired gas exchange was found in all cases without significant differences between the EFL and NEFL subjects. Application of 7.5 +/- 2.5 cm H2O of PEEP (range: 4-16) abolished EFL with a reduction of PEEPi and DH and an increase in FRC and the PEEPi inequality index but no significant effect on gas exchange. The present study indicates that: (a) on zero PEEP, EFL is present in most postoperative mechanically ventilated morbidly obese subjects; (b) EFL (and concurrent risk of low lung volume injury) is abolished with appropriate levels of PEEP; and (c) impaired gas exchange is common in these patients, probably mainly due to atelectasis.

  8. Complications in mechanically ventilated patients of Guillain–Barre syndrome and their prognostic value

    PubMed Central

    Netto, Archana Becket; Taly, Arun B.; Kulkarni, Girish B.; Uma Maheshwara Rao, G. S.; Rao, Shivaji

    2017-01-01

    Introduction: The spectrum of various complications in critically ill Guillain–Barre syndrome (GBS) and its effect on the prognosis is lacking in literature. This study aimed at enumerating the complications in such a cohort and their significance in the prognosis and mortality. Materials and Methods: Retrospective case record analysis of all consecutive mechanically ventilated patients of GBS in neurology Intensive Care Unit (ICU) of a tertiary care institute for 10 years was done. Demographic, laboratory, and treatment details and outcome parameters were recorded. Results: Among the 173 patients were 118 men and 55 women (2.1:1), aged 1–84 years. The average number of ICU complications per patient was 6.8 ± 1.8 (median = 7, range = 1–12). The most common complication was tracheobronchitis (128). Other pulmonary complications were found in 36 patients. The next was metabolic hyponatremia (115) hypokalemia (67), hypocalcemia (13), stress hyperglycemia (10), hyperkalemia (8), hypernatremia (9). Sepsis (40), UTI (47), dysautonomia (27), hypoalbuminemia (76), anemia (75), seizures (8), paralytic ileus (5), bleeding (4), anoxic encephalopathy (3), organ failures (12), deep vein thrombosis (7), and drug rashes (1) were also noted. The complications, considered significant in causing death, Hughes scale ≤ 3 at discharge, prolonged mechanical ventilation (>21 days) and hospitalization (>36 days) were pneumonia, hyponatremia, hypokalemia, urinary infection, tracheobronchial infections, hypoalbuminemia, sepsis, anemia dysautonomia. Conclusion: Active monitoring and appropriate and early intervention by the clinician will improve the quality of life of these patients and reduce the cost of prolonged mechanical ventilation and ICU stay. PMID:28149085

  9. Mechanical ventilation in ICUs in Poland: a multi-center point-prevalence study.

    PubMed

    Kübler, Andrzej; Maciejewski, Dariusz; Adamik, Barbara; Kaczorowska, Małgorzata

    2013-06-03

    Mechanical ventilation is the primary method of supporting organ function in patients treated in intensive care units (ICUs). Lung damage from mechanical ventilation can be avoided by using the correct ventilation modes. This study was designed to assess the epidemiology and treatment strategies of patients receiving mechanical ventilation in ICUs in Poland. This study was done using a point-prevalence methodology. Questionnaires requesting demographic data, indications for ventilation, variables involved in ventilation, airway access, methods of sedation, and mode of weaning were sent to 148 ICUs. Eighty-three ICUs took part in the study. The rate of ventilated patients was 73.6%. The indications for mechanical ventilation were: acute respiratory failure (40%), coma (40%), chronic obstructive pulmonary disease (COPD) exacerbation (14%), and neuromuscular diseases (5%). Patients were ventilated by orotracheal tube (58%), tracheostomy tube (41%), and mask/helmet (1%). The mean tidal volume was 8 ml/kg and positive end-expiratory pressure was commonly used. The mean oxygen concentration was 40%. Synchronized intermittent mandatory ventilation with pressure support was the most frequently used ventilatory mode. Benzodiazepine and opioids were used for sedation in 91% of centers. A systematic testing of the depth of sedation was performed at 48% surveyed ICUs. Ventilation monitoring with biomechanical methods was used at 53% of centers. Mechanical ventilation is commonly used in ICUs in Poland. Almost half of the ventilated patients had extrapulmonary indications. Patients were ventilated with low concentrations of oxygen, and positive end-expiratory pressure (PEEP) was commonly employed.

  10. Effect of the Prolonged Inspiratory to Expiratory Ratio on Oxygenation and Respiratory Mechanics During Surgical Procedures.

    PubMed

    Park, Jin Ha; Lee, Jong Seok; Lee, Jae Hoon; Shin, Seokyung; Min, Nar Hyun; Kim, Min-Soo

    2016-03-01

    Prolonged inspiratory to expiratory (I:E) ratio ventilation has been researched to reduce lung injury and improve oxygenation in surgical patients with one-lung ventilation (OLV) or carbon dioxide (CO2) pneumoperitoneum. We aimed to confirm the efficacy of the 1:1 equal ratio ventilation (ERV) compared with the 1:2 conventional ratio ventilation (CRV) during surgical procedures. Electronic databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched.Prospective interventional trials that assessed the effects of prolonged I:E ratio of 1:1 during surgical procedures. Adult patients undergoing OLV or CO2 pneumoperitoneum as specific interventions depending on surgical procedures. The included studies were examined with the Cochrane Collaboration's tool. The data regarding intraoperative oxygenation and respiratory mechanics were extracted, and then pooled with standardized mean difference (SMD) using the method of Hedges. Seven trials (498 total patients, 274 with ERV) were included. From overall analysis, ERV did not improve oxygenation at 20 or 30 minutes after specific interventions (SMD 0.193, 95% confidence interval (CI): -0.094 to 0.481, P = 0.188). From subgroup analyses, ERV provided significantly improved oxygenation only with laparoscopy (SMD 0.425, 95% CI: 0.167-0.682, P = 0.001). At 60 minutes after the specific interventions, ERV improved oxygenation significantly in the overall analysis (SMD 0.447, 95% CI: 0.209-0.685, P < 0.001) as well as in the subgroup analyses with OLV (SMD 0.328, 95% CI: 0.011-0.644, P = 0.042) and laparoscopy (SMD 0.668, 95% CI: 0.052-1.285, P = 0.034). ERV provided lower peak airway pressure (Ppeak) and plateau airway pressure (Pplat) than CRV, regardless of the type of intervention. The relatively small number of the included articles and their heterogeneity could be the main limitations. ERV improved oxygenation at all of the

  11. Pneumothorax, Pneumomediastinum, Pneumoperitoneum and Surgical Emphysema in Mechanically Ventilated Patients

    PubMed Central

    Kamha, A; Alzeer, H; Elithy, M

    2008-01-01

    A 29 year old male patient of Indian ancestry was admitted to an outside hospital with rapid deterioration of his level of consciousness. The patient required mechanical ventilation and transfer to MICU at Hamad Medical Corporation. The patient remained hypoxic. Chest X-ray, CT of chest, abdomen, pelvis and proximal areas of both lower limbs were performed. Pneumomediastinum, pneumoperitoneum, and extensive surgical emphysema were the diagnoses. PMID:21516154

  12. Ventilator-related causes of lung injury: the mechanical power.

    PubMed

    Gattinoni, L; Tonetti, T; Cressoni, M; Cadringher, P; Herrmann, P; Moerer, O; Protti, A; Gotti, M; Chiurazzi, C; Carlesso, E; Chiumello, D; Quintel, M

    2016-10-01

    We hypothesized that the ventilator-related causes of lung injury may be unified in a single variable: the mechanical power. We assessed whether the mechanical power measured by the pressure-volume loops can be computed from its components: tidal volume (TV)/driving pressure (∆P aw), flow, positive end-expiratory pressure (PEEP), and respiratory rate (RR). If so, the relative contributions of each variable to the mechanical power can be estimated. We computed the mechanical power by multiplying each component of the equation of motion by the variation of volume and RR: [Formula: see text]where ∆V is the tidal volume, ELrs is the elastance of the respiratory system, I:E is the inspiratory-to-expiratory time ratio, and R aw is the airway resistance. In 30 patients with normal lungs and in 50 ARDS patients, mechanical power was computed via the power equation and measured from the dynamic pressure-volume curve at 5 and 15 cmH2O PEEP and 6, 8, 10, and 12 ml/kg TV. We then computed the effects of the individual component variables on the mechanical power. Computed and measured mechanical powers were similar at 5 and 15 cmH2O PEEP both in normal subjects and in ARDS patients (slopes = 0.96, 1.06, 1.01, 1.12 respectively, R (2) > 0.96 and p < 0.0001 for all). The mechanical power increases exponentially with TV, ∆P aw, and flow (exponent = 2) as well as with RR (exponent = 1.4) and linearly with PEEP. The mechanical power equation may help estimate the contribution of the different ventilator-related causes of lung injury and of their variations. The equation can be easily implemented in every ventilator's software.

  13. 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

  14. Management and outcome of mechanically ventilated patients after cardiac arrest.

    PubMed

    Sutherasan, Yuda; Peñuelas, Oscar; Muriel, Alfonso; Vargas, Maria; Frutos-Vivar, Fernando; Brunetti, Iole; Raymondos, Konstantinos; D'Antini, Davide; Nielsen, Niklas; Ferguson, Niall D; Böttiger, Bernd W; Thille, Arnaud W; Davies, Andrew R; Hurtado, Javier; Rios, Fernando; Apezteguía, Carlos; Violi, Damian A; Cakar, Nahit; González, Marco; Du, Bin; Kuiper, Michael A; Soares, Marco Antonio; Koh, Younsuck; Moreno, Rui P; Amin, Pravin; Tomicic, Vinko; Soto, Luis; Bülow, Hans-Henrik; Anzueto, Antonio; Esteban, Andrés; Pelosi, Paolo

    2015-05-08

    The aim of this study was to describe and compare the changes in ventilator management and complications over time, as well as variables associated with 28-day hospital mortality in patients receiving mechanical ventilation (MV) after cardiac arrest. We performed a secondary analysis of three prospective, observational multicenter studies conducted in 1998, 2004 and 2010 in 927 ICUs from 40 countries. We screened 18,302 patients receiving MV for more than 12 hours during a one-month-period. We included 812 patients receiving MV after cardiac arrest. We collected data on demographics, daily ventilator settings, complications during ventilation and outcomes. Multivariate logistic regression analysis was performed to calculate odds ratios, determining which variables within 24 hours of hospital admission were associated with 28-day hospital mortality and occurrence of acute respiratory distress syndrome (ARDS) and pneumonia acquired during ICU stay at 48 hours after admission. Among 812 patients, 100 were included from 1998, 239 from 2004 and 473 from 2010. Ventilatory management changed over time, with decreased tidal volumes (VT) (1998: mean 8.9 (standard deviation (SD) 2) ml/kg actual body weight (ABW), 2010: 6.7 (SD 2) ml/kg ABW; 2004: 9 (SD 2.3) ml/kg predicted body weight (PBW), 2010: 7.95 (SD 1.7) ml/kg PBW) and increased positive end-expiratory pressure (PEEP) (1998: mean 3.5 (SD 3), 2010: 6.5 (SD 3); P <0.001). Patients included from 2010 had more sepsis, cardiovascular dysfunction and neurological failure, but 28-day hospital mortality was similar over time (52% in 1998, 57% in 2004 and 52% in 2010). Variables independently associated with 28-day hospital mortality were: older age, PaO2 <60 mmHg, cardiovascular dysfunction and less use of sedative agents. Higher VT, and plateau pressure with lower PEEP were associated with occurrence of ARDS and pneumonia acquired during ICU stay. Protective mechanical ventilation with lower VT and higher PEEP is more

  15. Hypervirulent Klebsiella pneumoniae induced ventilator-associated pneumonia in mechanically ventilated patients in China.

    PubMed

    Yan, Q; Zhou, M; Zou, M; Liu, W-e

    2016-03-01

    The purpose of this study was to investigate the clinical characteristics of hypervirulent K. pneumoniae (hvKP) induced ventilator-associated pneumonia (VAP) and the microbiological characteristics and epidemiology of the hvKP strains. A retrospective study of 49 mechanically ventilated patients with K. pneumoniae induced VAP was conducted at a university hospital in China from January 2014 to December 2014. Clinical characteristics and K. pneumoniae antimicrobial susceptibility and biofilm formation were analyzed. Genes of capsular serotypes K1, K2, K5, K20, K54 and K57 and virulence factors plasmid rmpA(p-rmpA), iroB, iucA, mrkD, entB, iutA, ybtS, kfu and allS were also evaluated. Multilocus sequence typing (MLST) and random amplified polymorphic DNA (RAPD) analyses were used to study the clonal relationship of the K. pneumoniae strains. Strains possessed p-rmpA and iroB and iucA were defined as hvKP. Of 49 patients, 14 patients (28.6 %) were infected by hvKP. Antimicrobial resistant rate was significantly higher in cKP than that in hvKP. One ST29 K54 extended-spectrum-beta-lactamase (ESBL) producing hvKP strain was detected. The prevalence of K1 and K2 in hvKP was 42.9 % and 21.4 %, respectively. The incidences of K1, K2, K20, p-rmpA, iroB, iucA, iutA, Kfu and alls were significantly higher in hvKP than those in cKP. ST23 was dominant among hvKP strains, and all the ST23 strains had identical RAPD pattern. hvKP has become a common pathogen of VAP in mechanically ventilated patients in China. Clinicians should increase awareness of hvKP induced VAP and enhance epidemiologic surveillance.

  16. [Design of a lung simulator for teaching lung mechanics in mechanical ventilation].

    PubMed

    Heili-Frades, Sarah; Peces-Barba, Germán; Rodríguez-Nieto, María Jesús

    2007-12-01

    Over the last 10 years, noninvasive ventilation has become a treatment option for respiratory insufficiency in pulmonology services. The technique is currently included in pulmonology teaching programs. Physicians and nurses should understand the devices they use and the interaction between the patient and the ventilator in terms of respiratory mechanics, adaptation, and synchronization. We present a readily assembled lung simulator for teaching purposes that is reproducible and interactive. Based on a bag-in-box system, this model allows the concepts of respiratory mechanics in mechanical ventilation to be taught simply and graphically in that it reproduces the patterns of restriction, obstruction, and the presence of leaks. It is possible to demonstrate how each ventilation parameter acts and the mechanical response elicited. It can also readily simulate asynchrony and demonstrate how this problem can be corrected.

  17. Mechanical ventilation for imaging the small animal lung.

    PubMed

    Hedlund, Laurence W; Johnson, G Allan

    2002-01-01

    This review emphasizes some of the challenges and benefits of in vivo imaging of the small animal lung. Because mechanical ventilation plays a key role in high-quality, high-resolution imaging of the small animal lung, the article focuses particularly on the problems of ventilation support, control of breathing motion and lung volume, and imaging during different phases of the breathing cycle. Solutions for these problems are discussed primarily in relation to magnetic resonance imaging, both conventional proton imaging and the newer, hyperpolarized helium imaging of pulmonary airways. Examples of applications of these imaging solutions to normal and diseased lung are illustrated in the rat and guinea pig. Although difficult to perform, pulmonary imaging in the small animal can be a valuable source of information not only for the normal lung, but also for the lung challenged by disease.

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

    PubMed

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

    2016-11-09

    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.

  19. Mechanical ventilation increases the inflammatory response induced by lung contusion.

    PubMed

    van Wessem, Karlijn J P; Hennus, Marije P; van Wagenberg, Linda; Koenderman, Leo; Leenen, Luke P H

    2013-07-01

    Posttraumatic lung contusion is common after blunt chest trauma, and patients often need ventilatory support. Lung contusion induces an inflammatory response signified by primed polymorph neutrophil granulocytes (PMNs) in blood and tissue. Mechanical ventilation (MV) can also cause an inflammatory response. The aim of this study was to develop an animal model to investigate the effect of high-volume ventilation on the inflammatory response in blunt chest trauma. We assigned 23 male Sprague-Dawley rats to either MV or bilateral lung contusion followed by MV. We used three extra rats as controls. Lung contusion was induced by a blast generator, a device releasing a single pressure blast wave centered on the chest. We determined tissue and systemic inflammation by absolute PMN numbers in blood and bronchoalveolar lavage fluid (BALF), myeloperoxidase, interleukin (IL)-6, IL 1β, growth-related oncogene-KC, and IL-10 in both plasma and BALF. Survival after blunt chest trauma was correlated to the distance to the blast generator. Compared with controls, both MV and blast plus MV rats showed increased systemic and pulmonary inflammation, expressed by higher PMNs, myeloperoxidase levels, and cytokine levels in both blood and BALF. Blast plus MV rats showed a higher systemic and pulmonary inflammatory response than MV rats. The blast generator generated reproducible blunt chest trauma in rats. Mechanical ventilation after lung contusion induced a larger overall inflammatory response than MV alone, which indicates that local damage contributes not only to local inflammation, but also to systemic inflammation. This emphasizes the importance of lung protective ventilation strategies after pulmonary contusion. Copyright © 2013 Elsevier Inc. All rights reserved.

  20. 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

  1. [The classification and risk analysis of clinical claims for mechanical ventilator].

    PubMed

    Liu, Yanwu; Wang, Ruitong; Xiao, Shengchun; Wang, Weidong

    2011-08-01

    The risk analysis of clinical claims of mechanical ventilator can provide the useful information to the application of the availability and safety of mechanical ventilators. This paper classifies the clinical claims of two types of mechanical ventilations, and tries to find the distribution characteristics of the failure rate of the clinical claims by using the hazard analysis method. All of the distribution characteristics are related to the factors as ventilator design, environment human factors, etc. The method of risk analysis, combining with the classification of clinical claims, is useful for the clinical application and engineering services of mechanical ventilation.

  2. Use of the virtual ventilator, a screen-based computer simulation, to teach the principles of mechanical ventilation.

    PubMed

    Keegan, Robert; Henderson, Tom; Brown, Gary

    2009-01-01

    Examination scores from 109 students enrolled in the professional veterinary program at Washington State University were evaluated to determine the effectiveness and utility of the Virtual Ventilator computer simulation for teaching the principles of mechanical ventilation in an anesthesia course. Students were randomly assigned to either a live-animal mechanical ventilation laboratory (LIVE-1st) or a computer laboratory using the mechanical ventilation simulation (SIM-1st) in week 1. During week 2, students in the LIVE-1st group participated in the ventilation simulation while students in the SIM-1st group participated in the live-animal laboratory. Student knowledge was evaluated using two similar written quizzes administered following each laboratory. Student opinions concerning the value of the simulation were assessed using an online survey. Differences in quiz scores within and between groups were compared using t-tests while survey results were tabulated. A p value of less than 0.05 was considered significant. Within the LIVE-1st group, scores for the second quiz, which was taken after the students had completed the simulation exercise, were significantly higher than those obtained from the first quiz. Accordingly, the Virtual Ventilator simulation was at least equivalent to the live-animal laboratory in the ability to present information that was subsequently tested for on the quizzes. Students in the SIM-1st group reported that use of the simulation prior to a live-animal ventilation laboratory enhanced their understanding of and ability to provide mechanical ventilation to anesthetized patients. The Virtual Ventilator simulation appears to be a useful and well-received teaching tool.

  3. 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.

  4. Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study.

    PubMed

    Zambon, Massimo; Beccaria, Paolo; Matsuno, Jun; Gemma, Marco; Frati, Elena; Colombo, Sergio; Cabrini, Luca; Landoni, Giovanni; Zangrillo, Alberto

    2016-07-01

    Mechanical ventilation contributes to diaphragmatic atrophy and dysfunction, and few techniques exist to assess diaphragmatic function: the purpose of this study was to quantify diaphragm atrophy in a population of critically ill mechanically ventilated patients with ultrasound and to identify risk factors that can worsen diaphragmatic activity. Prospective observational study. ICU of a 1,200-bed university hospital. Newly intubated adult critically ill patients. Diaphragm thickness in the zone of apposition was measured daily with ultrasound, from the first day of mechanical ventilation till discharge to the main ward. Daily atrophy rate (ΔTdi/d) was calculated as the reduction in percentage from the previous measurement. To analyze the difference in atrophy rate (ΔTdi/d), ventilation was categorized into four classes: spontaneous breathing or continuous positive airway pressure; pressure support ventilation 5-12 cm H2O (low pressure support ventilation); pressure support ventilation greater than 12 cm H2O (high pressure support ventilation); and controlled mechanical ventilation. Multivariate analysis with ventilation support and other clinical variables was performed to identify risk factors for atrophy. Forty patients underwent a total of 153 ultrasonographic evaluations. Mean (SD) ΔTdi/d was -7.5% (12.3) during controlled mechanical ventilation, -5.3% (12.9) at high pressure support ventilation, -1.5% (10.9) at low pressure support ventilation, +2.3% (9.5) during spontaneous breathing or continuous positive airway pressure. At multivariate analysis, only the ventilation support was predictive of diaphragm atrophy rate. Pressure support predicted diaphragm thickness with coefficient -0.006 (95% CI, -0.010 to -0.002; p = 0.006). In critically ill mechanically ventilated patients, there is a linear relationship between ventilator support and diaphragmatic atrophy rate.

  5. Pulmonary deposition of a nebulised aerosol during mechanical ventilation.

    PubMed Central

    Thomas, S H; O'Doherty, M J; Fidler, H M; Page, C J; Treacher, D F; Nunan, T O

    1993-01-01

    BACKGROUND: There is increasing use of therapeutic aerosols in patients undergoing mechanical ventilation. Few studies have measured aerosol delivery to the lungs under these conditions with adequate experimental methods. Hence this study was performed to measure pulmonary aerosol deposition and to determine the reproducibility of the method of measurement during mechanical ventilation. METHODS: Nine male patients were studied during mechanical ventilation after open heart surgery and two experiments were performed in each to determine the reproducibility of the method. A solution of technetium-99m labelled human serum albumin (99mTc HSA (50 micrograms); activity in experiment 1, 74 MBq; in experiment 2, 185 MBq) in 3 ml saline was administered with a Siemens Servo 945 nebuliser system (high setting) and a System 22 Acorn nebuliser unit. Pulmonary deposition was quantified by means of a gamma camera and corrections derived from lung phantom studies. RESULTS: Pulmonary aerosol deposition was completed in 22 (SD 4) minutes. Total pulmonary deposition (% nebuliser dose (SD)) was 2.2 (0.8)% with 1.5% and 0.7% depositing in the right and left lungs respectively; 0.9% of the nebuliser activity was detected in the endotracheal tube or trachea and 51% was retained within the nebuliser unit. Considerable variability between subjects was found for total deposition (coefficient of variation (CV) 46%), but within subject reproducibility was good (CV 15%). CONCLUSIONS: Administration of aerosol in this way is inefficient and further research is needed to find more effective alternatives in patients who require mechanical respiratory support. This method of measurement seems suitable for the assessment of new methods of aerosol delivery in these patients. Images PMID:8493630

  6. Impact of adding a filter for protection from toxic inhalational compounds to the ventilation circuit of mechanically ventilated patients.

    PubMed

    Be'eri, Eliezer; Owen, Simon; Shachar, Mark; Barlavie, Yaron; Eisenkraft, Arik

    2016-01-01

    Standard-issue Chemical-Biological-Radio-Nuclear (CBRN) gasmasks, as used for protection from non-conventional warfare agents or toxic industrial compounds, cannot be used by ventilated patients, leaving them exposed to toxic agents inhaled via their ventilators. This study was conducted to determine the safety of a CBRN filter added to the patient circuit of a ventilator, as a method for affording inhalational protection to ventilated patients. A Landrace pig was ventilated sequentially with 3 types of ventilators according to 17 different ventilation protocols, with and without a CBRN filters added in-line to the ventilation tubing for each protocol. For each protocol, physiological parameters, including oxygen saturation, inspired CO2, end tidal CO2, inspired oxygen, respiratory rate, and pulse rate, as well as airflow parameters including peak inspiratory pressure, positive end expiratory pressure and tidal volume were measured. The impact on the ventilator's trigger/sensitivity function was evaluated in vitro using a Michigan test lung. On average, the addition of the CBRN filter resulted in a 16 ml (5 %) decrease (range 0-50 ml) in the tidal volume, a 1.7 cm H2O (10 %) decrease (range 1-3 cm H2O) in the peak inspiratory pressure, and a 0.1 cm H2O (3 %) decrease (range 0-1 cm H2O) in the positive end expiratory pressure delivered to the animal. Some ventilators compensated for these airflow changes while others did not, depending on the design of the ventilator's pressure/flow sensing mechanism. Significant rebreathing occurred when the filter was positioned directly on the animal's endotracheal tube, but not when positioned on the air outflow port of the ventilator. In vitro measurements showed that the addition of the CBRN filter added a mean pressure gradient of 0.45 cm H2O to the trigger/sensitivity function of the system. In-line addition of a CBRN filter to ventilation tubing is a feasible strategy for affording inhalational protection to

  7. 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

  8. 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.

  9. Components of respiratory resistance monitored in mechanically ventilated patients.

    PubMed

    Babik, B; Peták, F; Asztalos, T; Deák, Z I; Bogáts, G; Hantos, Z

    2002-12-01

    The interrupter technique is commonly adopted to monitor respiratory resistance (Rrs,int) during mechanical ventilation; however, Rrs,int is often interpreted as an index of airway resistance (Raw). This study compared the values of Rrs,int provided by a Siemens 940 Lung Mechanics Monitor with total respiratory impedance (Zrs) parameters in 39 patients with normal spirometric parameters, who were undergoing elective coronary bypass surgery. Zrs was determined at the airway opening with pseudorandom oscillations of 0.2-6 Hz at end inspiration. Raw and tissue resistance (Rti) were derived from the Zrs data by model fitting; Rti and total resistance (Rrs,osc=Raw+Rti) were calculated at the actual respirator frequencies. Lower airway resistance (Rawl) was estimated by measuring tracheal pressure. Although good agreement was obtained between Rrs,osc and Rrs,int, with a ratio of 1.07+/-0.19 (mean+/-SD), they correlated poorly (r2=0.36). Rti and the equipment component of Raw accounted for most of Rrs,osc (39.8+/-11.9 and 43.0+/-6.9%, respectively), whereas only a small portion belonged to Rawl (17.2+/-6.3%). It is concluded that respiratory resistance may become very insensitive to changes in lower airway resistance and therefore, inappropriate for following alterations in airway tone during mechanical ventilation, especially in patients with relatively normal respiratory mechanics, where the tissue and equipment resistances represent the vast majority of the total resistance.

  10. 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.

  11. 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

  12. Communication of mechanically ventilated patients in intensive care units.

    PubMed

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

    2016-06-01

    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. 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. 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). 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 presence of other clinical and

  13. Effects of manual hyperinflation in preterm newborns under mechanical ventilation

    PubMed Central

    Viana, Camila Chaves; Nicolau, Carla Marques; Juliani, Regina Celia Turola Passos; de Carvalho, Werther Brunow; Krebs, Vera Lucia Jornada

    2016-01-01

    Objective To assess the effects of manual hyperinflation, performed with a manual resuscitator with and without the positive end-expiratory pressure valve, on the respiratory function of preterm newborns under mechanical ventilation. Methods Cross-sectional study of hemodynamically stable preterm newborns with gestational age of less than 32 weeks, under mechanical ventilation and dependent on it at 28 days of life. Manual hyperinflation was applied randomly, alternating the use or not of the positive end-expiratory pressure valve, followed by tracheal aspiration for ending the maneuver. For nominal data, the two-tailed Wilcoxon test was applied at the 5% significance level and 80% power. Results Twenty-eight preterm newborns, with an average birth weight of 1,005.71 ± 372.16g, an average gestational age of 28.90 ± 1.79 weeks, an average corrected age of 33.26 ± 1.78 weeks, and an average mechanical ventilation time of 29.5 (15 - 53) days, were studied. Increases in inspiratory and expiratory volumes occurred between time-points A5 (before the maneuver) and C1 (immediately after tracheal aspiration) in both the maneuver with the valve (p = 0.001 and p = 0.009) and without the valve (p = 0.026 and p = 0.001), respectively. There was also an increase in expiratory resistance between time-points A5 and C1 (p = 0.044). Conclusion Lung volumes increased when performing the maneuver with and without the valve, with a significant difference in the first minute after aspiration. There was a significant difference in expiratory resistance between the time-points A5 (before the maneuver) and C1 (immediately after tracheal aspiration) in the first minute after aspiration within each maneuver. PMID:27737427

  14. Comparison of respiratory and hemodynamic stability in patients with traumatic brain injury ventilated by two ventilator modes: Pressure regulated volume control versus synchronized intermittent mechanical ventilation

    PubMed Central

    Aghadavoudi, Omid; Alikiaii, Babak; Sadeghi, Fariba

    2016-01-01

    Background: This study aimed to compare pressure regulated volume control (PRVC) and synchronized intermittent mechanical ventilation (SIMV) modes of ventilation according to respiratory and hemodynamic stability in patients with traumatic brain injury (TBI) admitted to Intensive Care Unit (ICU). Materials and Methods: In a randomized, single-blinded, clinical trial study, 100 patients who hospitalized in ICU due to TBI were selected and randomly divided into two groups. The first and second groups were ventilated by PRVC and SIMV modes, respectively. During mechanical ventilation, arterial blood gas and respiratory and hemodynamic parameters were also recorded and compared between the two groups. Results: According to the t-test, the mean rapid shallow breathing index (RSBI) after the first 8 h of mechanical ventilation was significantly higher in SIMV group compared with PRVC group (107.6 ± 2.75 vs. 102.2 ± 5.2, respectively, P < 0.0001). Further, according to ANOVA with repeated measures, the trend of RSBI changes had a significant difference between the two groups (P < 0.001). The trend of ratio of partial pressure arterial oxygen and fraction of inspired oxygen was different between the two groups according to Mann–Whitney–Wilcoxon test (P < 0.001). Conclusions: Using PRVC mode might be more desirable than using SIMV mode in patients with TBI due to better stability of ventilation and oxygenating. To ensure for more advantages of PRVC mode, further studies with longer follow-up and more detailed measurements are recommended. PMID:28028515

  15. Respiratory syncytial virus infection in children admitted to hospital but ventilated mechanically for other reasons.

    PubMed

    von Renesse, Anja; Schildgen, Oliver; Klinkenberg, Dennis; Müller, Andreas; von Moers, Arpad; Simon, Arne

    2009-01-01

    One thousand five hundred sixty-eight RSV infections were documented prospectively in 1,541 pediatric patients. Of these, 20 (1.3%) had acquired the RSV infection while treated by mechanical ventilation for reasons other than the actual RSV infection (group ventilated mechanically). The clinical characteristics of children who were infected with respiratory syncytial virus (RSV) infection while ventilated mechanically for other reasons are described and compared with a matched control group. Sixty percent of the group ventilated mechanically had at least one additional risk factor for a severe course of infection (prematurity 50%, chronic lung disease 20%, congenital heart disease 35%, immunodeficiency 20%). The median age at diagnosis in the group ventilated mechanically was 4.2 months. The matched pairs analysis (group ventilated mechanically vs. control group) revealed a higher proportion of patients with hypoxemia and apnoea in the group ventilated mechanically; more patients in the control group showed symptoms of airway obstruction (wheezing). At least one chest radiography was performed in 95% of the patients (n = 19) in the group ventilated mechanically versus 45% (n = 9) in the control group (P = 0.001). The frequency of pneumonia was 40% in the group ventilated mechanically and 20% in the control group. Despite existing consensus recommendations, only two patients (10%) of the group ventilated mechanically had received palivizumab previously. Significantly more patients in the group ventilated mechanically received antibiotic treatment (85% vs. 45%, P = 0.008), and attributable mortality was higher in the group ventilated mechanically (15% [n = 3] vs. 0% in the control group, P = 0.231). Children treated by long term mechanical ventilation may acquire RSV infection by transmission by droplets or caregivers and face an increased risk of a severe course of RSV infection. The low rate of immunoprophylaxis in this particular risk group should be improved.

  16. Practice of excessive F(IO(2)) and effect on pulmonary outcomes in mechanically ventilated patients with acute lung injury.

    PubMed

    Rachmale, Sonal; Li, Guangxi; Wilson, Gregory; Malinchoc, Michael; Gajic, Ognjen

    2012-11-01

    Optimal titration of inspired oxygen is important to prevent hyperoxia in mechanically ventilated patients in ICUs. There is mounting evidence of the deleterious effects of hyperoxia; however, there is a paucity of data about F(IO(2)) practice and oxygen exposure among patients in ICUs. We therefore sought to assess excessive F(IO(2)) exposure in mechanically ventilated patients with acute lung injury and to evaluate the effect on pulmonary outcomes. From a database of ICU patients with acute lung injury identified by prospective electronic medical record screening, we identified those who underwent invasive mechanical ventilation for > 48 hours from January 1 to December 31, 2008. Ventilator settings, including F(IO(2)) and corresponding S(pO(2)), were collected from the electronic medical record at 15-min intervals for the first 48 hours. Excessive F(IO(2)) was defined as F(IO(2)) > 0.5 despite S(pO(2)) > 92%. The association between the duration of excessive exposure and pulmonary outcomes was assessed by change in oxygenation index from baseline to 48 hours and was analyzed by univariate and multivariate linear regression analysis. Of 210 patients who met the inclusion criteria, 155 (74%) were exposed to excessive F(IO(2)) for a median duration of 17 hours (interquartile range 7.5-33 h). Prolonged exposure to excessive F(IO(2)) correlated with worse oxygenation index at 48 hours in a dose-response manner (P < .001.). Both exposure to higher F(IO(2)) and longer duration of exposure were associated with worsening oxygenation index at 48 hours (P < .001), more days on mechanical ventilation, longer ICU stay, and longer hospital stay (P = .004). No mortality difference was noted. Excessive oxygen supplementation is common in mechanically ventilated patients with ALI and may be associated with worsening lung function.

  17. Inhibition of Janus kinase signaling during controlled mechanical ventilation prevents ventilation-induced diaphragm dysfunction.

    PubMed

    Smith, Ira J; Godinez, Guillermo L; Singh, Baljit K; McCaughey, Kelly M; Alcantara, Raniel R; Gururaja, Tarikere; Ho, Melissa S; Nguyen, Henry N; Friera, Annabelle M; White, Kathy A; McLaughlin, John R; Hansen, Derek; Romero, Jason M; Baltgalvis, Kristen A; Claypool, Mark D; Li, Wei; Lang, Wayne; Yam, George C; Gelman, Marina S; Ding, Rongxian; Yung, Stephanie L; Creger, Daniel P; Chen, Yan; Singh, Rajinder; Smuder, Ashley J; Wiggs, Michael P; Kwon, Oh-Sung; Sollanek, Kurt J; Powers, Scott K; Masuda, Esteban S; Taylor, Vanessa C; Payan, Donald G; Kinoshita, Taisei; Kinsella, Todd M

    2014-07-01

    Controlled mechanical ventilation (CMV) is associated with the development of diaphragm atrophy and contractile dysfunction, and respiratory muscle weakness is thought to contribute significantly to delayed weaning of patients. Therefore, therapeutic strategies for preventing these processes may have clinical benefit. The aim of the current study was to investigate the role of the Janus kinase (JAK)/signal transducer and activator of transcription 3 (STAT3) signaling pathway in CMV-mediated diaphragm wasting and weakness in rats. CMV-induced diaphragm atrophy and contractile dysfunction coincided with marked increases in STAT3 phosphorylation on both tyrosine 705 (Tyr705) and serine 727 (Ser727). STAT3 activation was accompanied by its translocation into mitochondria within diaphragm muscle and mitochondrial dysfunction. Inhibition of JAK signaling during CMV prevented phosphorylation of both target sites on STAT3, eliminated the accumulation of phosphorylated STAT3 within the mitochondria, and reversed the pathologic alterations in mitochondrial function, reduced oxidative stress in the diaphragm, and maintained normal diaphragm contractility. In addition, JAK inhibition during CMV blunted the activation of key proteolytic pathways in the diaphragm, as well as diaphragm atrophy. These findings implicate JAK/STAT3 signaling in the development of diaphragm muscle atrophy and dysfunction during CMV and suggest that the delayed extubation times associated with CMV can be prevented by inhibition of Janus kinase signaling.-Smith, I. J., Godinez, G. L., Singh, B. K., McCaughey, K. M., Alcantara, R. R., Gururaja, T., Ho, M. S., Nguyen, H. N., Friera, A. M., White, K. A., McLaughlin, J. R., Hansen, D., Romero, J. M., Baltgalvis, K. A., Claypool, M. D., Li, W., Lang, W., Yam, G. C., Gelman, M. S., Ding, R., Yung, S. L., Creger, D. P., Chen, Y., Singh, R., Smuder, A. J., Wiggs, M. P., Kwon, O.-S., Sollanek, K. J., Powers, S. K., Masuda, E. S., Taylor, V. C., Payan, D. G

  18. Inhibition of Janus kinase signaling during controlled mechanical ventilation prevents ventilation-induced diaphragm dysfunction

    PubMed Central

    Smith, Ira J.; Godinez, Guillermo L.; Singh, Baljit K.; McCaughey, Kelly M.; Alcantara, Raniel R.; Gururaja, Tarikere; Ho, Melissa S.; Nguyen, Henry N.; Friera, Annabelle M.; White, Kathy A.; McLaughlin, John R.; Hansen, Derek; Romero, Jason M.; Baltgalvis, Kristen A.; Claypool, Mark D.; Li, Wei; Lang, Wayne; Yam, George C.; Gelman, Marina S.; Ding, Rongxian; Yung, Stephanie L.; Creger, Daniel P.; Chen, Yan; Singh, Rajinder; Smuder, Ashley J.; Wiggs, Michael P.; Kwon, Oh-Sung; Sollanek, Kurt J.; Powers, Scott K.; Masuda, Esteban S.; Taylor, Vanessa C.; Payan, Donald G.; Kinoshita, Taisei; Kinsella, Todd M.

    2014-01-01

    Controlled mechanical ventilation (CMV) is associated with the development of diaphragm atrophy and contractile dysfunction, and respiratory muscle weakness is thought to contribute significantly to delayed weaning of patients. Therefore, therapeutic strategies for preventing these processes may have clinical benefit. The aim of the current study was to investigate the role of the Janus kinase (JAK)/signal transducer and activator of transcription 3 (STAT3) signaling pathway in CMV-mediated diaphragm wasting and weakness in rats. CMV-induced diaphragm atrophy and contractile dysfunction coincided with marked increases in STAT3 phosphorylation on both tyrosine 705 (Tyr705) and serine 727 (Ser727). STAT3 activation was accompanied by its translocation into mitochondria within diaphragm muscle and mitochondrial dysfunction. Inhibition of JAK signaling during CMV prevented phosphorylation of both target sites on STAT3, eliminated the accumulation of phosphorylated STAT3 within the mitochondria, and reversed the pathologic alterations in mitochondrial function, reduced oxidative stress in the diaphragm, and maintained normal diaphragm contractility. In addition, JAK inhibition during CMV blunted the activation of key proteolytic pathways in the diaphragm, as well as diaphragm atrophy. These findings implicate JAK/STAT3 signaling in the development of diaphragm muscle atrophy and dysfunction during CMV and suggest that the delayed extubation times associated with CMV can be prevented by inhibition of Janus kinase signaling.—Smith, I. J., Godinez, G. L., Singh, B. K., McCaughey, K. M., Alcantara, R. R., Gururaja, T., Ho, M. S., Nguyen, H. N., Friera, A. M., White, K. A., McLaughlin, J. R., Hansen, D., Romero, J. M., Baltgalvis, K. A., Claypool, M. D., Li, W., Lang, W., Yam, G. C., Gelman, M. S., Ding, R., Yung, S. L., Creger, D. P., Chen, Y., Singh, R., Smuder, A. J., Wiggs, M. P., Kwon, O.-S., Sollanek, K. J., Powers, S. K., Masuda, E. S., Taylor, V. C., Payan, D. G

  19. 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

  20. Mechanisms of prolonged lithium therapy-induced nephrogenic diabetes insipidus.

    PubMed

    Behl, Tapan; Kotwani, Anita; Kaur, Ishneet; Goel, Heena

    2015-05-15

    Nephrogenic diabetes insipidus is a clinical sub-type of a diversely expounded disorder, named diabetes insipidus. It is characterized by inability of the renal cells to sense and respond to the stimulus of vasopressin. Amongst its various etiologies, one of the most inevitable causes includes lithium-induced instigation. Numerous studies reported marked histological damage to the kidneys upon long-term treatment with lithium. The recent researches have hypothesized many lithium-mediated mechanisms to explain the damage and dysfunction caused in the kidneys following lithium exposure. These mechanisms, widely, intend to justify the lithium-induced electrolyte imbalance, its interference with some vital proteins and a specific steroidal hormone, obstruction caused to a certain imperative transducer pathway and the renal tubular acidification defect produced on its prolonged therapy. Thorough study of such mechanisms aids in better understanding of the role of lithium in the pathophysiology of this disorder. Hence, the ameliorated knowledge regarding disease-pathology might prove beneficial in developing therapies that aim on disrupting the various lithium-mediated pathways. Hence, this may effectively lead to the demonstration of a novel treatment for nephrogenic diabetes insipidus, which is, at present, limited to the use of diuretics which block lithium reuptake into the body. Copyright © 2015 Elsevier B.V. All rights reserved.

  1. Optimal Delivery of Aerosols to Infants During Mechanical Ventilation

    PubMed Central

    Azimi, Mandana; Hindle, Michael

    2014-01-01

    Abstract Purpose: The objective of this study was to determine optimal aerosol delivery conditions for a full-term (3.6 kg) infant receiving invasive mechanical ventilation by evaluating the effects of aerosol particle size, a new wye connector, and timing of aerosol delivery. Methods: In vitro experiments used a vibrating mesh nebulizer and evaluated drug deposition fraction and emitted dose through ventilation circuits containing either a commercial (CM) or new streamlined (SL) wye connector and 3-mm endotracheal tube (ETT) for aerosols with mass median aerodynamic diameters of 880 nm, 1.78 μm, and 4.9 μm. The aerosol was released into the circuit either over the full inhalation cycle (T1 delivery) or over the first half of inhalation (T2 delivery). Validated computational fluid dynamics (CFD) simulations and whole-lung model predictions were used to assess lung deposition and exhaled dose during cyclic ventilation. Results: In vitro experiments at a steady-state tracheal flow rate of 5 L/min resulted in 80–90% transmission of the 880-nm and 1.78-μm aerosols from the ETT. Based on CFD simulations with cyclic ventilation, the SL wye design reduced depositional losses in the wye by a factor of approximately 2–4 and improved lung delivery efficiencies by a factor of approximately 2 compared with the CM device. Delivery of the aerosol over the first half of the inspiratory cycle (T2) reduced exhaled dose from the ventilation circuit by a factor of 4 compared with T1 delivery. Optimal lung deposition was achieved with the SL wye connector and T2 delivery, resulting in 45% and 60% lung deposition for optimal polydisperse (∼1.78 μm) and monodisperse (∼2.5 μm) particle sizes, respectively. Conclusions: Optimization of selected factors and use of a new SL wye connector can substantially increase the lung delivery efficiency of medical aerosols to infants from current values of <1–10% to a range of 45–60%. PMID:24299500

  2. Optimal delivery of aerosols to infants during mechanical ventilation.

    PubMed

    Longest, P Worth; Azimi, Mandana; Hindle, Michael

    2014-10-01

    The objective of this study was to determine optimal aerosol delivery conditions for a full-term (3.6 kg) infant receiving invasive mechanical ventilation by evaluating the effects of aerosol particle size, a new wye connector, and timing of aerosol delivery. In vitro experiments used a vibrating mesh nebulizer and evaluated drug deposition fraction and emitted dose through ventilation circuits containing either a commercial (CM) or new streamlined (SL) wye connector and 3-mm endotracheal tube (ETT) for aerosols with mass median aerodynamic diameters of 880 nm, 1.78 μm, and 4.9 μm. The aerosol was released into the circuit either over the full inhalation cycle (T1 delivery) or over the first half of inhalation (T2 delivery). Validated computational fluid dynamics (CFD) simulations and whole-lung model predictions were used to assess lung deposition and exhaled dose during cyclic ventilation. In vitro experiments at a steady-state tracheal flow rate of 5 L/min resulted in 80-90% transmission of the 880-nm and 1.78-μm aerosols from the ETT. Based on CFD simulations with cyclic ventilation, the SL wye design reduced depositional losses in the wye by a factor of approximately 2-4 and improved lung delivery efficiencies by a factor of approximately 2 compared with the CM device. Delivery of the aerosol over the first half of the inspiratory cycle (T2) reduced exhaled dose from the ventilation circuit by a factor of 4 compared with T1 delivery. Optimal lung deposition was achieved with the SL wye connector and T2 delivery, resulting in 45% and 60% lung deposition for optimal polydisperse (∼1.78 μm) and monodisperse (∼2.5 μm) particle sizes, respectively. Optimization of selected factors and use of a new SL wye connector can substantially increase the lung delivery efficiency of medical aerosols to infants from current values of <1-10% to a range of 45-60%.

  3. Instantaneous responses to high-frequency chest wall oscillation in patients with acute pneumonic respiratory failure receiving mechanical ventilation

    PubMed Central

    Chuang, Ming-Lung; Chou, Yi-Ling; Lee, Chai-Yuan; Huang, Shih-Feng

    2017-01-01

    Abstract Background: Endotracheal intubation and prolonged immobilization of patients receiving mechanical ventilation may reduce expectoration function. High-frequency chest wall oscillation (HFCWO) may ameliorate airway secretion movement; however, the instantaneous changes in patients’ cardiopulmonary responses are unknown. Moreover, HFCWO may influence ventilator settings by the vigorous oscillation. The aim of this study was to investigate these issues. Methods: Seventy-three patients (52 men) aged 71.5 ± 13.4 years who were intubated with mechanical ventilation for pneumonic respiratory failure were recruited and randomly classified into 2 groups (HFCWO group, n = 36; and control group who received conventional chest physical therapy (CCPT, n = 37). HFCWO was applied with a fixed protocol, whereas CCPT was conducted using standard protocols. Both groups received sputum suction after the procedure. Changes in ventilator settings and the subjects’ responses were measured at preset intervals and compared within groups and between groups. Results: Oscillation did not affect the ventilator settings (all P > 0.05). The mean airway pressure, breathing frequency, and rapid shallow breathing index increased, and the tidal volume and SpO2 decreased (all P < 0.05). After sputum suction, the peak airway pressure (Ppeak) and minute ventilation decreased (all P < 0.05). The HFCWO group had a lower tidal volume and SpO2 at the end of oscillation, and lower Ppeak and tidal volume after sputum suction than the CCPT group. Conclusions: HFCWO affects breathing pattern and SpO2 but not ventilator settings, whereas CCPT maintains a steadier condition. After sputum suction, HFCWO slightly improved Ppeak compared to CCPT, suggesting that the study extends the indications of HFCWO for these patients in intensive care unit. (ClinicalTrials.gov number NCT02758106, retrospectively registered.) PMID:28248854

  4. Carbon dioxide elimination and oxygen consumption in mechanically ventilated children.

    PubMed

    Smallwood, Craig D; Walsh, Brian K; Bechard, Lori J; Mehta, Nilesh M

    2015-05-01

    Accurate measurement of carbon dioxide elimination (V̇CO2 ) and oxygen consumption (V̇O2 ) at the bedside may help titrate nutritional and respiratory support in mechanically ventilated patients. Continuous V̇CO2 monitoring is now available with many ventilators. However, because normative data are sparsely available in the literature, we aimed to describe the range of V̇CO2 and V̇O2 values observed in mechanically ventilated children. We also aimed to examine the characteristics of V̇CO2 values that are associated with standard steady state (5-min period when V̇CO2 and V̇O2 variability are < 10%). Mechanically ventilated patients who underwent indirect calorimetry testing were eligible for inclusion, and subjects who achieved standard steady state were included. Normalized V̇CO2 and V̇O2 values (mL/kg/min) were modeled against subject height, and correlation coefficients were computed to quantify the goodness of fit. A steady-state definition using only V̇CO2 was developed (V̇CO2 variability of < 5% for a 5-min period) and tested against standard steady state using sensitivity and specificity. Steady-state data from 87 indirect calorimetry tests (in 70 subjects) were included. For age groups < 0.5, 0.5-8, and > 8 y, the mean V̇CO2 values were 7.6, 5.8, and 3.5 mL/kg/min. Normalized V̇CO2 and V̇O2 values were inversely related to subject height and age. The relationships between normalized gas exchange values and height were demonstrated by the models: V̇CO2 = 115 × (height in cm)(-0.71) (R = 0.61, P < .001) and V̇O2 = 130 × (height in cm)(-0.72) (R = 0.61, P < .001). Steady-state V̇CO2 predicted standard steady state (sensitivity of 0.84, specificity of 1.0, P < .01). V̇CO2 and V̇O2 measurements correlated with subject height and age. Smaller and younger subjects produced larger amounts of CO2 and consumed more O2 per unit of body weight. The use of a 5-min period when V̇CO2 varied by < 5% predicted standard steady state. Our observations

  5. Mechanical ventilation weaning protocol improves medical adherence and results.

    PubMed

    Borges, Luís Guilherme Alegretti; Savi, Augusto; Teixeira, Cassiano; de Oliveira, Roselaine Pinheiro; De Camillis, Marcio Luiz Ferreira; Wickert, Ricardo; Brodt, Sérgio Fernando Monteiro; Tonietto, Túlio Frederico; Cremonese, Ricardo; da Silva, Leonardo Silveira; Gehm, Fernanda; Oliveira, Eubrando Silvestre; Barth, Jose Herve Diel; Macari, Juçara Gasparetto; de Barros, Cíntia Dias; Vieira, Sílvia Regina Rios

    2017-10-01

    Implementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. We investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. We enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001). A multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation

  6. Impact of tongue biofilm removal on mechanically ventilated patients

    PubMed Central

    Santos, Paulo Sérgio da Silva; Mariano, Marcelo; Kallas, Monira Samaan; Vilela, Maria Carolina Nunes

    2013-01-01

    Objective To evaluate the effectiveness of a tongue cleaner in the removal of tongue biofilm in mechanically ventilated patients. Methods Tongue biofilm and tracheal secretion samples were collected from a total of 50 patients: 27 in the study group (SG) who were intubated or tracheostomized under assisted ventilation and treated with the tongue cleaner and 23 in the control group (CG) who did not undergo tongue cleaning. Oral and tracheal secretion cultures of the SG (initially and after 5 days) and the CG (at a single time-point) were performed to evaluate the changes in bacterial flora. Results The median age of the SG patients was 77 years (45-99 years), and that of the CG patients was 79 years (21-94 years). The length of hospital stay ranged from 17-1,370 days for the SG with a median stay of 425 days and from 4-240 days for the CG with a median stay of 120 days. No significant differences were found when the dental plaque indexes were compared between the SG and the CG. There was no correlation between the index and the length of hospital stay. The same bacterial flora was found in the dental plaque of 9 of the 27 SG patients before and after the tongue scraper was used for 5 days compared with the CG (p=0.683). Overall, 7 of the 27 SG patients had positive bacterial cultures for the same strains in both tongue biofilm and tracheal secretions compared with the CG (p=0.003). Significant similarities in strain resistance and susceptibility of the assessed microorganisms were observed between oral and tracheal microflora in 6/23 cases in the CG (p=0.006). Conclusion The use of a tongue cleaner is effective at reducing tongue biofilm in patients on mechanical ventilation and facilitates oral hygiene interventions performed by caregivers. Clinical Trials Registry NCT01294943 PMID:23887759

  7. Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation.

    PubMed

    Casetti, Alfredo V; Bartlett, Robert H; Hirschl, Ronald B

    2002-10-01

    Ventilator-induced lung injury may be caused by overdistension of alveoli during high-pressure ventilation. In this study, we examined the effects of increasing inspiratory time on ventilator-induced lung injury. Sprague-Dawley rats were divided into four different groups with ten animals per group. Each group was then ventilated for 30 mins with one of four ventilator strategies. All groups were ventilated with an Fio2 of 1.0 and a positive end-expiratory pressure of 0 cm H2O. Group LoP was the negative control group and was ventilated with low pressures (peak inspiratory pressure = 12 cm H2O, rate = 30, and inspiratory time = 0.5 secs). Groups iT = 0.5, iT = 1.0, and iT = 1.5 were the experimental groups and were ventilated with high pressures (peak inspiratory pressure = 45 cm H2O, rate = 10, and inspiratory times = 0.5 secs, iT = 1.0 sec, and iT = 1.5 secs, respectively). Outcome measures included lung compliance, Pao /Fio ratio, wet/dry lung weight, and dry lung/body weight. Final static lung compliance (p =.0002) and Pao2/Fio2 (p =.001) decreased as inspiratory time increased. Wet/dry lung weights (p <.0001) and dry lung/body weights (p <.0001) increased as inspiratory time increased. Light microscopy revealed evidence of intra-alveolar edema and hemorrhage in the iT = 1.0 and iT = 1.5 animals but not the LoP and iT = 0.5 animals. Increasing inspiratory time during high-pressure/high-volume mechanical ventilation is associated with an increase in variables of lung injury.

  8. Mechanical ventilation modulates TLR4 and IRAK-3 in a non-infectious, ventilator-induced lung injury model.

    PubMed

    Villar, Jesús; Cabrera, Nuria E; Casula, Milena; Flores, Carlos; Valladares, Francisco; Díaz-Flores, Lucio; Muros, Mercedes; Slutsky, Arthur S; Kacmarek, Robert M

    2010-03-03

    Previous experimental studies have shown that injurious mechanical ventilation has a direct effect on pulmonary and systemic immune responses. How these responses are propagated or attenuated is a matter of speculation. The goal of this study was to determine the contribution of mechanical ventilation in the regulation of Toll-like receptor (TLR) signaling and interleukin-1 receptor associated kinase-3 (IRAK-3) during experimental ventilator-induced lung injury. Prospective, randomized, controlled animal study using male, healthy adults Sprague-Dawley rats weighing 300-350 g. Animals were anesthetized and randomized to spontaneous breathing and to two different mechanical ventilation strategies for 4 hours: high tidal volume (VT) (20 ml/kg) and low VT (6 ml/kg). Histological evaluation, TLR2, TLR4, IRAK3 gene expression, IRAK-3 protein levels, inhibitory kappa B alpha (IkappaBalpha), tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL6) gene expression in the lungs and TNF-alpha and IL-6 protein serum concentrations were analyzed. High VT mechanical ventilation for 4 hours was associated with a significant increase of TLR4 but not TLR2, a significant decrease of IRAK3 lung gene expression and protein levels, a significant decrease of IkappaBalpha, and a higher lung expression and serum concentrations of pro-inflammatory cytokines. The current study supports an interaction between TLR4 and IRAK-3 signaling pathway for the over-expression and release of pro-inflammatory cytokines during ventilator-induced lung injury. Our study also suggests that injurious mechanical ventilation may elicit an immune response that is similar to that observed during infections.

  9. Adequacy of oxygenation parameters in elderly patients undergoing mechanical ventilation

    PubMed Central

    Guedes, Luana Petruccio Cabral Monteiro; Delfino, Fabrício Costa; de Faria, Flavia Perassa; de Melo, Gislane Ferreira; Carvalho, Gustavo de Azevedo

    2013-01-01

    ABSTRACT Objective: To compare ideal PaO2 with PaO2 found, ideal PaO2/FiO2 of room air with the one found, and ideal FiO2 with FiO2 found in mechanically ventilated elderly patients. Methods: Cross-sectional study that evaluated elderly mechanically ventilated patients for at least 72 hours and who underwent three subsequent blood gas analyses. Results: The sample consisted of 48 elderly with mean age of 74.77±9.36 years. There was a significant difference between the ideal PaO2 and the one found (p<0.001), between FiO2 corrected and the offered one, and also between ideal PaO2/FiO2 of room air and the PaO2/FiO2 found (p<0,001). Conclusion: A significant increase was seen in PaO2 and FiO2 and in alterations of gas exchange by PaO2/FiO2 index than those found in normal parameters. PMID:24488386

  10. Noninvasive mechanical ventilation and acute respiratory failure: indications and limitations.

    PubMed

    Muir, J F; Cuvelier, A; Verin, E; Tengang, B

    1997-02-01

    Noninvasive mechanical ventilation (NMV) now represents the first step in the management of acute on chronic respiratory failure (A/CRF). During the last 5 yrs, many studies have confirmed the feasibility of NMV in an acute setting, either by facial or nasal interface, used in addition to volumetric or barometric respirators, to manage A/CRF. The best indications for NMV are slowly progressive A/CRF, frequently represented by chronic obstructive pulmonary disease (COPD), or restrictive pulmonary disease. The criteria to initiate NMV in such patients are worsening of respiratory status and arterial blood gas (ABG) values, with increased hypoxia, hypercapnia and respiratory acidosis, despite optimal management with medication, physiotherapy and oxygen therapy. Respiratory encephalopathy is not an absolute contraindication; however, bronchial hypersecretion indicates that care is needed under NMV. Invasive mechanical ventilation with endotracheal (ET) intubation is discussed in the case of failure of NMV, when clinical status and ABG values worsen in spite of it. The signal for ET intubation is then obvious, represented by severe dyspnoea leading to respiratory pauses or arrest, severe cyanosis, and signs of haemodynamic instability. Despite immediate evidence of ominous cardiorespiratory inefficiency, ET intubation may be delayed and often avoided with the help of NMV. Criteria should be studied to identify guidelines for cessation of NMV, in order not to continue with the technique too long considering the safety of the patient. Indications for NMV in other kinds of ARF have received less study and are more controversial.

  11. Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds

    PubMed Central

    Teno, Joan M.; Gozalo, Pedro; Khandelwal, Nita; Curtis, J. Randall; Meltzer, David; Engelberg, Ruth; Mor, Vincent

    2016-01-01

    IMPORTANCE Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit. OBJECTIVE To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients’ demographic characteristics, function, and comorbidities. MAIN OUTCOMES AND MEASURES Mechanical ventilation. RESULTS From 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5% male and 69.5% female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95% CI, 1.05–1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2% vs 64.6%; P = 54). CONCLUSIONS AND RELEVANCE Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time

  12. Successful Lung Transplantation Using a Deceased Donor Mechanically Ventilated for Ten Months.

    PubMed

    Tanaka, Shin; Miyoshi, Kentaroh; Sugimoto, Seiichiro; Yamane, Masaomi; Kobayashi, Motomu; Oto, Takahiro

    2017-08-01

    A successful outcome after lung transplant was achieved using lungs donated from a teenage boy who underwent prolonged mechanical ventilation. The donor experienced hypoxic brain damage and was declared brain dead 324 days after tracheal intubation. At the time of referral, the donor's lungs revealed diffuse radiologic infiltration and atelectasis but excellent function, with a PaO2/FiO2 ratio of 450. The lungs were transplanted to a 10-year-old girl with bronchiolitis obliterans. She developed grade 2 primary graft dysfunction, but recovered quickly. She is doing well and has not experienced any other critical adverse events 12 months after lung transplantation. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  13. Regional tidal lung strain in mechanically ventilated normal lungs.

    PubMed

    Paula, Luis Felipe; Wellman, Tyler J; Winkler, Tilo; Spieth, Peter M; Güldner, Andreas; Venegas, Jose G; Gama de Abreu, Marcelo; Carvalho, Alysson R; Vidal Melo, Marcos F

    2016-12-01

    Parenchymal strain is a key determinant of lung injury produced by mechanical ventilation. However, imaging estimates of volumetric tidal strain (ε = regional tidal volume/reference volume) present substantial conceptual differences in reference volume computation and consideration of tidally recruited lung. We compared current and new methods to estimate tidal volumetric strains with computed tomography, and quantified the effect of tidal volume (VT) and positive end-expiratory pressure (PEEP) on strain estimates. Eight supine pigs were ventilated with VT = 6 and 12 ml/kg and PEEP = 0, 6, and 12 cmH2O. End-expiratory and end-inspiratory scans were analyzed in eight regions of interest along the ventral-dorsal axis. Regional reference volumes were computed at end-expiration (with/without correction of regional VT for intratidal recruitment) and at resting lung volume (PEEP = 0) corrected for intratidal and PEEP-derived recruitment. All strain estimates demonstrated vertical heterogeneity with the largest tidal strains in middependent regions (P < 0.01). Maximal strains for distinct estimates occurred at different lung regions and were differently affected by VT-PEEP conditions. Values consistent with lung injury and inflammation were reached regionally, even when global measurements were below critical levels. Strains increased with VT and were larger in middependent than in nondependent lung regions. PEEP reduced tidal-strain estimates referenced to end-expiratory lung volumes, although it did not affect strains referenced to resting lung volume. These estimates of tidal strains in normal lungs point to middependent lung regions as those at risk for ventilator-induced lung injury. The different conditions and topography at which maximal strain estimates occur allow for testing the importance of each estimate for lung injury.

  14. Update on clinical trials in home mechanical ventilation.

    PubMed

    Hodgson, Luke E; Murphy, Patrick B

    2016-02-01

    Home mechanical ventilation (HMV) is an increasingly common intervention and is initiated for a range of pathological processes, including neuromuscular disease (NMD), chronic obstructive pulmonary disease (COPD) and obesity related respiratory failure. There have been important recent data published in this area, which helps to guide practice by indicating which populations may benefit from this intervention and the optimum method of setting up and controlling sleep disordered breathing. Recent superficially conflicting data has been published regarding HMV in COPD, with a trial in post-exacerbation patients suggesting no benefit, but in stable chronic hypercapnic patients suggesting a clear and sustained mortality benefit. The two studies are critiqued and the potential reasons for the differing results are discussed. Early and small trial data is frequently contradicted with larger randomised controlled trials and this has been the case with diaphragm pacing being shown to be potentially harmful in the latest data, confirming the importance of non-invasive ventilation (NIV) in NMD such as motor neurone disease. Advances in ventilator technology have so far appeared quicker than the clinical data to support their use; although small and often unblinded, the current data suggests equivalence to standard modes of NIV, but with potential comfort benefits that may enhance adherence. The indications for NIV have expanded since its inception, with an effort to treat sleep disordered breathing as a result of chronic heart failure (HF). The SERVE-HF trial has recently demonstrated no clear advantage to this technology and furthermore detected a potentially deleterious effect, with a worsening of all cause and cardiovascular mortality in the treated group compared to controls. The review serves to provide the reader with a critical review of recent advances in the field of sleep disordered breathing and HMV.

  15. Exhaled breath condensate pH in mechanically ventilated patients.

    PubMed

    Nannini, L J; Quintana, R; Bagilet, D H; Druetta, M; Ramírez, M; Nieto, R; Guelman Greta, G

    2013-12-01

    In this prospective clinical trial we aimed to answer if spontaneous exhaled breath condensate (EBC) in the trap of the expiratory arm of the ventilator could replace EBC collected by coolant chamber standardized with Argon as an inert gas. Second, if EBC pH could predict ventilator associated pneumonia (VAP) and mortality. We included 34 critically ill patients (males = 26), aged = 54.85 ± 19.86 (mean ± SD) yrs, that required mechanical ventilation due to non-pulmonary direct cause (APACHE II score = 23.58 ± 14.7; PaO(2)/FiO(2) = 240.00 ± 98.29). ICU with 9 beds from a regional teaching hospital. The patients were followed up until development of VAP, successful weaning or death. There were significant differences between mean EBC pH from the 4 procedures with the exception of spontaneous EBC de-aerated with Argon (n = 79; 6.74 ± 0.28) and coolant chamber deaerated with Argon (n = 79; 6.70 ± 0.36; p = NS by Tukey's Multiple Comparison Test). However, none of the procedures were extrapolated between each other according to Bland & Altman method. The mean EBC pH from the trap without Argon was 6.50 ± 0.28. From the total of 34 patients, 22 survived and were discharged and 12 patients died in the ICU. Spontaneous EBC pH could not be extrapolated to EBC pH from coolant chamber and it did not change in subjects who dead, neither subject with VAP in comparison with baseline data. The lack of other biomarker in EBC and the lack of a control group determinate the need for further studies in this setting. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  16. [Pneumomediastinum: an aspect of pulmonary barotrauma during mechanical ventilation of acute respiratory distress syndrome].

    PubMed

    Aissaoui, Y; En-Nafaa, I; Chkoura, K; Boughalem, M; Kamili, N Drissi

    2014-06-01

    Mechanical ventilation is a fundamental treatment of acute respiratory distress syndrome (ARDS). Despite compliance with the recommendations of protective mechanical ventilation, it can results in serious complications including the pulmonary barotrauma. This is often manifested by a pneumothorax. This observation describes an unusual aspect of barotrauma which is pneumomediastinum. The authors also point out the role of chest imaging in the management of mechanical ventilation during ARDS. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

  17. Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation.

    PubMed

    Unoki, Takeshi; Kawasaki, Yuri; Mizutani, Taro; Fujino, Yoko; Yanagisawa, Yaeko; Ishimatsu, Shinichi; Tamura, Fumiko; Toyooka, Hidenori

    2005-11-01

    Expiratory rib-cage compression, a chest physiotherapy technique, is well known as the "squeezing" technique in Japan. To determine the effects of rib-cage compression on airway-secretion removal, oxygenation, and ventilation in patients receiving mechanical ventilation. An intensive care unit of an emergency and critical care center at a tertiary-care teaching hospital in Tokyo, Japan. Thirty-one intubated, mechanically ventilated patients in an intensive care unit were studied in a randomized, crossover trial. The patients received endotracheal suctioning with or without rib-cage compression, with a minimum 3-hour interval between the 2 interventions. Rib-cage compression was performed for 5 min before endotracheal suctioning. Arterial blood gas and respiratory mechanics were measured 5 min before endotracheal suctioning (baseline) and 25 min after suctioning. The 2 measurement periods were carried out on the same day. There were no significant differences in the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, P(aCO2), or dynamic compliance of the respiratory system between the 2 periods (before and after endotracheal suctioning). Moreover, there were no significant differences in airway-secretion removal between the 2 periods. This study suggests that rib-cage compression prior to endotracheal suctioning does not improve airway-secretion removal, oxygenation, or ventilation after endotracheal suctioning in this unselected population of mechanically ventilated patients.

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

    PubMed Central

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

    2015-01-01

    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. PMID:26561823

  19. 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.

  20. Fifty Years of Research in ARDS. Spontaneous Breathing during Mechanical Ventilation. Risks, Mechanisms, and Management.

    PubMed

    Yoshida, Takeshi; Fujino, Yuji; Amato, Marcelo B P; Kavanagh, Brian P

    2017-04-15

    Spontaneous respiratory effort during mechanical ventilation has long been recognized to improve oxygenation, and because oxygenation is a key management target, such effort may seem beneficial. Also, disuse and loss of peripheral muscle and diaphragm function is increasingly recognized, and thus spontaneous breathing may confer additional advantage. Reflecting this, epidemiologic data suggest that the use of partial (vs. full) support modes of ventilation is increasing. Notwithstanding the central place of spontaneous breathing in mechanical ventilation, accumulating evidence indicates that it may cause-or worsen-acute lung injury, especially if acute respiratory distress syndrome is severe and spontaneous effort is vigorous. This Perspective reviews the evidence for this phenomenon, explores mechanisms of injury, and provides suggestions for clinical management and future research.

  1. Mechanical ventilation in ICUs in Poland: A multi-center point-prevalence study

    PubMed Central

    Kübler, Andrzej; Maciejewski, Dariusz; Adamik, Barbara; Kaczorowska, Małgorzata

    2013-01-01

    Background Mechanical ventilation is the primary method of supporting organ function in patients treated in intensive care units (ICUs). Lung damage from mechanical ventilation can be avoided by using the correct ventilation modes. This study was designed to assess the epidemiology and treatment strategies of patients receiving mechanical ventilation in ICUs in Poland. Material/Methods This study was done using a point-prevalence methodology. Questionnaires requesting demographic data, indications for ventilation, variables involved in ventilation, airway access, methods of sedation, and mode of weaning were sent to 148 ICUs. Results Eighty-three ICUs took part in the study. The rate of ventilated patients was 73.6%. The indications for mechanical ventilation were: acute respiratory failure (40%), coma (40%), chronic obstructive pulmonary disease (COPD) exacerbation (14%), and neuromuscular diseases (5%). Patients were ventilated by orotracheal tube (58%), tracheostomy tube (41%), and mask/helmet (1%). The mean tidal volume was 8 ml/kg and positive end-expiratory pressure was commonly used. The mean oxygen concentration was 40%. Synchronized intermittent mandatory ventilation with pressure support was the most frequently used ventilatory mode. Benzodiazepine and opioids were used for sedation in 91% of centers. A systematic testing of the depth of sedation was performed at 48% surveyed ICUs. Ventilation monitoring with biomechanical methods was used at 53% of centers. Conclusions Mechanical ventilation is commonly used in ICUs in Poland. Almost half of the ventilated patients had extrapulmonary indications. Patients were ventilated with low concentrations of oxygen, and positive end-expiratory pressure (PEEP) was commonly employed. PMID:23727991

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

    PubMed Central

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

    2007-01-01

    Introduction 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 cmH20) and low positive end-expiratory pressure (PEEP of 3 cmH2O) did not initially result in altered alveolar mechanics, but alveolar instability developed over time. Methods 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, Pcontrol = 14 cmH2O, PEEP = 3 cmH2O), high pressure/low PEEP group (n = 6, Pcontrol = 45 cmH2O, PEEP = 3 cmH2O), and high pressure/high PEEP group (n = 5, Pcontrol = 45 cmH2O, PEEP = 10 cmH2O). 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 – EΔ). Results Alveoli were stable in the control group for the entire experiment (low %I – EΔ). Alveoli in the high pressure/low PEEP group were initially stable (low %I – EΔ), 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. Conclusion A

  3. Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning.

    PubMed

    Välitalo, P A; Krekels, E H; van Dijk, M; Simons, Shp; Tibboel, D; Knibbe, C A

    2017-04-01

    To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT-B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple-item pain scores. The analysis showed an intra-individual relationship between morphine concentrations and pain reduction, as measured by COMFORT-B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates. © 2017 The Authors CPT: Pharmacometrics & Systems Pharmacology published by Wiley Periodicals, Inc. on behalf of American Society for Clinical Pharmacology and Therapeutics.

  4. Control of Breathing During Mechanical Ventilation: Who Is the Boss?

    PubMed Central

    Williams, Kathleen; Hinojosa-Kurtzberg, Marina; Parthasarathy, Sairam

    2011-01-01

    Over the past decade, concepts of control of breathing have increasingly moved from being theoretical concepts to “real world” applied science. The purpose of this review is to examine the basics of control of breathing, discuss the bidirectional relationship between control of breathing and mechanical ventilation, and critically assess the application of this knowledge at the patient’s bedside. The principles of control of breathing remain under-represented in the training curriculum of respiratory therapists and pulmonologists, whereas the day-to-day bedside application of the principles of control of breathing continues to suffer from a lack of outcomes-based research in the intensive care unit. In contrast, the bedside application of the principles of control of breathing to ambulatory subjects with sleep-disordered breathing has out-stripped that in critically ill patients. The evolution of newer technologies, faster real-time computing abilities, and miniaturization of ventilator technology can bring the concepts of control of breathing to the bedside and benefit the critically ill patient. However, market forces, lack of scientific data, lack of research funding, and regulatory obstacles need to be surmounted. PMID:21333174

  5. The role of tracheostomy in weaning from mechanical ventilation.

    PubMed

    Jaeger, J Michael; Littlewood, Keith A; Durbin, Charles G

    2002-04-01

    A common clinical observation is that patients wean more rapidly from mechanical ventilation following tracheotomy. Expected changes in tube resistance and dead space are not adequate to explain this observation in adult patients. Theoretical considerations are too complicated to allow evaluation of expected changes in work of breathing following tracheotomy. The resistance of the upper airway is about the same as breathing quietly through an 8.0 mm endotracheal tube; however, many patients experience a higher work of breathing following extubation. This is not true in infants, in whom the reduction in airway diameter is profound and a marked reduction in resistance is seen following extubation. The other benefits of tracheostomy include better secretion removal, improved oral hygiene, less laryngeal damage, and ability to eat and speak. These should be considered when proposing this procedure. There may be less late ventilator-associated pneumonia following early tracheotomy. The assumed better safety of tracheostomy has been questioned. That patients appear to wean more rapidly is probably accounted for by the variety of factors mentioned above.

  6. Incidence and causes of non-invasive mechanical ventilation failure after initial success

    PubMed Central

    Moretti, M.; Cilione, C.; Tampieri, A.; Fracchia, C.; Marchioni, A.; Nava, S.

    2000-01-01

    BACKGROUND—The rate of failure of non-invasive mechanical ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD) with acute respiratory insufficiency ranges from 5% to 40%. Most of the studies report an incidence of "late failure" (after >48 hours of NIMV) of about 10-20%. The recognition of this subset of patients is critical because prolonged application of NIMV may unduly delay the time of intubation.
METHODS—In this multicentre study the primary aims were to assess the rate of "late NIMV failure" and possible associated predictive factors; secondary aims of the study were evaluation of the best ventilatory strategy in this subset of patients and their outcomes in and out of hospital. The study was performed in two respiratory intensive care units (ICUs) on patients with COPD admitted with an episode of hypercapnic respiratory failure (mean (SD) pH 7.23(0.07), PaCO2 85.3 (15.8) mm Hg).
RESULTS—One hundred and thirty seven patients initially responded to NIMV in terms of objective (arterial blood gas tensions) and subjective improvement. After 8.4 (2.8) days of NIMV 31 patients (23%; 95% confidence interval (CI) 18 to 33) experienced a new episode of acute respiratory failure while still ventilated. The occurrence of "late NIMV failure" was significantly associated with functional limitations (ADL scale) before admission to the respiratory ICU, the presence of medical complications (particularly hyperglycaemia), and a lower pH on admission. Depending on their willingness or not to be intubated, the patients received invasive ventilation (n=19) or "more aggressive" (more hours/day) NIMV (n=12). Eleven (92%) of those in this latter subgroup died while in the respiratory ICU compared with 10 (53%) of the patients receiving invasive ventilation. The overall 90 day mortality was 21% and, after discharge from hospital, was similar in the "late NIMV failure" group and in patients who did not experience a second episode of acute

  7. [Clinical significance of dynamic pressure-volume curve in neonatal mechanical ventilation].

    PubMed

    Zhu, Yuan-Peng; Ma, Li-Ya; Wu, Zhi-Jun; Lu, Guang-Jin; Han, Yu-Kun

    2009-07-01

    To study the characteristics and role of dynamic pressure-volume curve (P-V curve) in neonatal mechanical ventilation. A dynamic P-V curve was automatically drawn by the Stephanie ventilator. The slope rate of dynamic P-V curve was measured in 25 neonates who received mechanical ventilation 1, 24, 48 and 72 hrs after ventilation and before weaning from ventilation. Minute-ventilation (MV), mean airway pressure (Pmean), and fraction of inspired oxygen (FiO2) were recorded. The patterns of dynamic P-V curve during abnormal ventilation (resistance to ventilator, part or complete airway obstruction, airway leaking and tracheal catheter exodus) were observed. With the improvement of pulmonary disease, the slope rate of P-V curve and MV increased, Pmean and FiO2 decreased, and the P-V curve shifted to the volume axle. The slope rate of curve 48 and 72 hrs after ventilation and before weaning from ventilation (1.05+/-0.48, 1.10+/-0.42 and 1.13+/-0.37 mL/cmH2O respectively) increased significantly compared with that 1 hr after ventilation (0.76+/-0.53 mL/cmH2O) (p<0.05 or 0.01). Abnormal ventilation led to abnormal appearance of dynamic P-V curve. The increasing slope rate of dynamic P-V curve and the curve shifting to volume axle in neonatal mechanical ventilation may be associated with the improvement of pulmonary disease. The appearance changes of the curve may be of value in the assessment of abnormal ventilation.

  8. Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients.

    PubMed

    Blackwood, Bronagh; Murray, Maeve; Chisakuta, Anthony; Cardwell, Chris R; O'Halloran, Peter

    2013-07-31

    Mechanical ventilation is a critical component of paediatric intensive care therapy. It is indicated when the patient's spontaneous ventilation is inadequate to sustain life. Weaning is the gradual reduction of ventilatory support and the transfer of respiratory control back to the patient. Weaning may represent a large proportion of the ventilatory period. Prolonged ventilation is associated with significant morbidity, hospital cost, psychosocial and physical risks to the child and even death. Timely and effective weaning may reduce the duration of mechanical ventilation and may reduce the morbidity and mortality associated with prolonged ventilation. However, no consensus has been reached on criteria that can be used to identify when patients are ready to wean or the best way to achieve it. To assess the effects of weaning by protocol on invasively ventilated critically ill children. To compare the total duration of invasive mechanical ventilation of critically ill children who are weaned using protocols versus those weaned through usual (non-protocolized) practice. To ascertain any differences between protocolized weaning and usual care in terms of mortality, adverse events, intensive care unit length of stay and quality of life. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 10, 2012), MEDLINE (1966 to October 2012), EMBASE (1988 to October 2012), CINAHL (1982 to October 2012), ISI Web of Science and LILACS. We identified unpublished data in the Web of Science (1990 to October 2012), ISI Conference Proceedings (1990 to October 2012) and Cambridge Scientific Abstracts (earliest to October 2012). We contacted first authors of studies included in the review to obtain further information on unpublished studies or work in progress. We searched reference lists of all identified studies and review papers for further relevant studies. We applied no language or publication restrictions. We included randomized

  9. Mechanical ventilation and lung infection in the genesis of air-space enlargement

    PubMed Central

    Sartorius, Alfonso; Lu, Qin; Vieira, Silvia; Tonnellier, Marc; Lenaour, Gilles; Goldstein, Ivan; Rouby, Jean-Jacques

    2007-01-01

    Introduction Air-space enlargement may result from mechanical ventilation and/or lung infection. The aim of this study was to assess how mechanical ventilation and lung infection influence the genesis of bronchiolar and alveolar distention. Methods Four groups of piglets were studied: non-ventilated-non-inoculated (controls, n = 5), non-ventilated-inoculated (n = 6), ventilated-non-inoculated (n = 6), and ventilated-inoculated (n = 8) piglets. The respiratory tract of intubated piglets was inoculated with a highly concentrated solution of Escherichia coli. Mechanical ventilation was maintained during 60 hours with a tidal volume of 15 ml/kg and zero positive end-expiratory pressure. After sacrifice by exsanguination, lungs were fixed for histological and lung morphometry analyses. Results Lung infection was present in all inoculated piglets and in five of the six ventilated-non-inoculated piglets. Mean alveolar and mean bronchiolar areas, measured using an analyzer computer system connected through a high-resolution color camera to an optical microscope, were significantly increased in non-ventilated-inoculated animals (+16% and +11%, respectively, compared to controls), in ventilated-non-inoculated animals (+49% and +49%, respectively, compared to controls), and in ventilated-inoculated animals (+95% and +118%, respectively, compared to controls). Mean alveolar and mean bronchiolar areas significantly correlated with the extension of lung infection (R = 0.50, p < 0.01 and R = 0.67, p < 0.001, respectively). Conclusion Lung infection induces bronchiolar and alveolar distention. Mechanical ventilation induces secondary lung infection and is associated with further air-space enlargement. The combination of primary lung infection and mechanical ventilation markedly increases air-space enlargement, the degree of which depends on the severity and extension of lung infection. PMID:17274806

  10. Mechanical ventilation: past lessons and the near future

    PubMed Central

    2013-01-01

    The ability to compensate for life-threatening failure of respiratory function is perhaps the signature technology of intensive care medicine. Unchanging needs for providing effective life-support with minimized risk and optimized comfort have been, are now, and will be the principal objectives of providing mechanical ventilation. Important lessons acquired over nearly half-a-century of ICU care have brought us closer to meeting them, as technological advances in instrumentation now effectively put this hard-won knowledge into action. Rising demand in the face of economic constraints is likely to drive future innovations focused on reducing the need for user input, automating multi-element protocols, and carefully monitoring the patient for progress and complications. PMID:23514222

  11. Opioid Analgesics for Sedation and Analgesia During Mechanical Ventilation.

    PubMed

    Zeller, Brandy; Giebe, Jeanne

    2015-01-01

    Neonates are exposed to repetitive pain and stress during their stay in a NICU, which can lead to chronic complications related to their neurodevelopment and neurobehavior. Approximately 20 percent of all neonates in a NICU are intubated, mechanically ventilated, and require suctioning, which can cause both acute and chronic pain. Pain management in the neonate can be challenging. Nurses and other caregivers need to be well trained to assess pain in the neonate to effectively identify and provide appropriate pain management strategies. There is a lack of evidence to support routine administration of opiates in the neonate. As with any medication, the possibility of short- and long-term adverse reactions must be considered. Nonpharmacologic therapy should be used as much as possible.

  12. Mechanical ventilation: past lessons and the near future.

    PubMed

    Marini, John J

    2013-01-01

    The ability to compensate for life-threatening failure of respiratory function is perhaps the signature technology of intensive care medicine. Unchanging needs for providing effective life-support with minimized risk and optimized comfort have been, are now, and will be the principal objectives of providing mechanical ventilation. Important lessons acquired over nearly half-a-century of ICU care have brought us closer to meeting them, as technological advances in instrumentation now effectively put this hard-won knowledge into action. Rising demand in the face of economic constraints is likely to drive future innovations focused on reducing the need for user input, automating multi-element protocols, and carefully monitoring the patient for progress and complications.

  13. Resolution of obstructive atelectasis with non-invasive mechanical ventilation.

    PubMed

    Mirambeaux Villalona, Rosa; Mayoralas Alises, Sagrario; Díaz Lobato, Salvador

    2014-10-01

    Bronchoscopy is a commonly used technique in patients with atelectasis due to mucus plugs. We present here the case of an 82-year-old patient with a history of Meige's syndrome who developed acute respiratory failure due to atelectasis of the right upper lobe associated with hospital-acquired pneumonia. The patient had a severely reduced level of consciousness, significant work-of-breathing and severe hypercapnic acidosis, all of which contraindicated bronchoscopy. Bi-level noninvasive mechanical ventilation (NIMV) was initiated by way of a face mask. Progress was favourable, with clear clinical and gasometric improvement. The chest X-ray performed 12hours later showed complete resolution of the atelectasis. These data suggest that NIMV may be useful in the treatment of atelectasis is some critical patients. Copyright © 2013 SEPAR. Published by Elsevier Espana. All rights reserved.

  14. Quantitative investigation of alveolar structures with OCT using total liquid ventilation during mechanical ventilation

    NASA Astrophysics Data System (ADS)

    Schnabel, Christian; Gaertner, Maria; Meissner, Sven; Koch, Edmund

    2012-02-01

    To develop new treatment possibilities for patients with severe lung diseases it is crucial to understand the lung function on an alveolar level. Optical coherence tomography (OCT) in combination with intravital microscopy (IVM) are used for imaging subpleural alveoli in animal models to gain information about dynamic and morphological changes of lung tissue during mechanical ventilation. The image content suitable for further analysis is influenced by image artifacts caused by scattering, refraction, reflection, and absorbance. Because the refractive index varies with each air-tissue interface in lung tissue, these effects decrease OCT image quality exceedingly. The quality of OCT images can be increased when the refractive index inside the alveoli is matched to the one of tissue via liquid-filling. Thereby, scattering loss can be decreased and higher penetration depth and tissue contrast can be achieved. To use the advantages of liquid-filling for in vivo imaging of small rodent lungs, a suitable breathing fluid (perfluorodecalin) and a special liquid respirator are necessary. Here we show the effect of liquid-filling on OCT and IVM image quality of subpleural alveoli in a mouse model.

  15. Evaluation of the user interface simplicity in the modern generation of mechanical ventilators.

    PubMed

    Uzawa, Yoshihiro; Yamada, Yoshitsugu; Suzukawa, Masayuki

    2008-03-01

    We designed this study to evaluate the simplicity of the user interface in modern-generation mechanical ventilators. We hypothesized that different designs in the user interface could result in different rates of operational failures. A laboratory in a tertiary teaching hospital. Crossover design. Twenty-one medical resident physicians who did not possess operating experience with any of the selected ventilators. Four modern mechanical ventilators were selected: Dräger Evita XL, Maquet Servo-i, Newport e500, and Puritan Bennett 840. Each subject was requested to perform 8 tasks on each ventilator. Two objective variables (the number of successfully completed tasks without operational failures and the operational time) and the overall subjective rating of the ease of use, measured with a 100-mm visual analog scale were recorded. The total percentage of operational failures made for all subjects, for all tasks, was 23%. There were significant differences in the rates of operational failures and operational time among the 4 ventilators. Subjects made more operational failures in setting up the ventilators and in making ventilator-setting changes than in reacting to alarms. The subjective feeling of the ease of use was also significantly different among the ventilators. The design of the user interface is relevant to the occurrence of operational failures. Our data indicate that ventilator designers could optimize the user-interface design to reduce the operational failures; therefore, basic user interface should be standardized among the clinically used mechanical ventilators.

  16. Technology for noninvasive mechanical ventilation: looking into the black box

    PubMed Central

    Navajas, Daniel; Montserrat, Josep M.

    2016-01-01

    Current devices for providing noninvasive respiratory support contain sensors and built-in intelligence for automatically modifying ventilation according to the patient's needs. These devices, including automatic continuous positive airway pressure devices and noninvasive ventilators, are technologically complex and offer a considerable number of different modes of ventilation and setting options, the details of which are sometimes difficult to capture by the user. Therefore, better predicting and interpreting the actual performance of these ventilation devices in clinical application requires understanding their functioning principles and assessing their performance under well controlled bench test conditions with simulated patients. This concise review presents an updated perspective of the theoretical basis of intelligent continuous positive airway pressure and noninvasive ventilation devices, and of the tools available for assessing how these devices respond under specific ventilation phenotypes in patients requiring breathing support. PMID:27730162

  17. Prognostic impact of mechanical ventilation after liver transplantation: A national database study

    PubMed Central

    Yuan, Hui; Tuttle-Newhall, Janet E.; Chawa, Vikram; Schnitzler, Mark A.; Xiao, Huiling; Axelrod, David; Dzebisashvili, Nino; Lentine, Krista L.

    2015-01-01

    Background The impact of mechanical ventilator support (MCVS) on mortality and graft loss after liver transplantation (LT) is not well-described. Methods Multivariate analysis of a novel database linking national transplant registry and Medicare claims data was used to assess the impact of early MCVS on mortality and graft survival following LTs performed between 2002–2008. Results Among 10,517 LT recipients, 6.9% (n=726) required post-operative MCVS, 25.6% of who required < 96 hrs, 24.2% ≥ 96 hrs, and 50.1% an unspecified duration. Significant predictors of prolonged MCVS included older age, female gender, pre-transplant dialysis requirement and ascites. After multivariate adjustment, MCVS ≥96hrs was associated with nearly 3-times the adjusted hazard ratio (aHR) of mortality (2.95, P=<0.001), while MCVS <96 hrs was not significantly associated with mortality (aHR 0.88, P=0.55). Conclusions Recognition of LT patients at-risk for prolonged MCVS may help to reduce the incidence and consequences of this complication. PMID:25151187

  18. Xanthine oxidase contributes to mechanical ventilation-induced diaphragmatic oxidative stress and contractile dysfunction.

    PubMed

    Whidden, Melissa A; McClung, Joseph M; Falk, Darin J; Hudson, Matthew B; Smuder, Ashley J; Nelson, W Bradley; Powers, Scott K

    2009-02-01

    Respiratory muscle weakness resulting from both diaphragmatic contractile dysfunction and atrophy has been hypothesized to contribute to the weaning difficulties associated with prolonged mechanical ventilation (MV). While it is clear that oxidative injury contributes to MV-induced diaphragmatic weakness, the source(s) of oxidants in the diaphragm during MV remain unknown. These experiments tested the hypothesis that xanthine oxidase (XO) contributes to MV-induced oxidant production in the rat diaphragm and that oxypurinol, a XO inhibitor, would attenuate MV-induced diaphragmatic oxidative stress, contractile dysfunction, and atrophy. Adult female Sprague-Dawley rats were randomly assigned to one of six experimental groups: 1) control, 2) control with oxypurinol, 3) 12 h of MV, 4) 12 h of MV with oxypurinol, 5) 18 h of MV, or 6) 18 h of MV with oxypurinol. XO activity was significantly elevated in the diaphragm after MV, and oxypurinol administration inhibited this activity and provided protection against MV-induced oxidative stress and contractile dysfunction. Specifically, oxypurinol treatment partially attenuated both protein oxidation and lipid peroxidation in the diaphragm during MV. Further, XO inhibition retarded MV-induced diaphragmatic contractile dysfunction at stimulation frequencies >60 Hz. Collectively, these results suggest that oxidant production by XO contributes to MV-induced oxidative injury and contractile dysfunction in the diaphragm. Nonetheless, the failure of XO inhibition to completely prevent MV-induced diaphragmatic oxidative damage suggests that other sources of oxidant production are active in the diaphragm during prolonged MV.

  19. What is the proper approach to liberating the weak from mechanical ventilation?

    PubMed

    Brochard, Laurent; Thille, Arnaud W

    2009-10-01

    The general issue of weaning can be viewed as composed of three different groups of patients. First, simple or easy weaning, represents 60% to 70% of patients whose first trial of spontaneous breathing is successful. The main objective of the weaning process is to detect weaning readiness as early as possible, which is best achieved using a systematic approach. The percentage of patients in this group in a given intensive care unit represents the pretest probability of weaning. A second group is made of patients who experience failure of the first spontaneous breathing trial and in whom up to 7 days from the first trial may be required to achieve weaning. This group represents 20% to 25% of patients who undergo weaning from mechanical ventilation. Muscle weakness contributes to the prolongation of weaning in many of these patients. The last group is made of patients who are characterized by a prolonged or very difficult weaning process (about 5% to 15% of patients undergoing weaning). Muscle weakness is likely to be a major contributing factor. Early use of spontaneous breathing, well-controlled use of sedation, and early mobilization may help in reducing muscle weakness and hasten the weaning process. The postextubation period may be particularly at risk in these patients. More research is needed to guide clinicians regarding the best ventilatory management.

  20. Xanthine oxidase contributes to mechanical ventilation-induced diaphragmatic oxidative stress and contractile dysfunction

    PubMed Central

    Whidden, Melissa A.; McClung, Joseph M.; Falk, Darin J.; Hudson, Matthew B.; Smuder, Ashley J.; Nelson, W. Bradley; Powers, Scott K.

    2009-01-01

    Respiratory muscle weakness resulting from both diaphragmatic contractile dysfunction and atrophy has been hypothesized to contribute to the weaning difficulties associated with prolonged mechanical ventilation (MV). While it is clear that oxidative injury contributes to MV-induced diaphragmatic weakness, the source(s) of oxidants in the diaphragm during MV remain unknown. These experiments tested the hypothesis that xanthine oxidase (XO) contributes to MV-induced oxidant production in the rat diaphragm and that oxypurinol, a XO inhibitor, would attenuate MV-induced diaphragmatic oxidative stress, contractile dysfunction, and atrophy. Adult female Sprague-Dawley rats were randomly assigned to one of six experimental groups: 1) control, 2) control with oxypurinol, 3) 12 h of MV, 4) 12 h of MV with oxypurinol, 5) 18 h of MV, or 6) 18 h of MV with oxypurinol. XO activity was significantly elevated in the diaphragm after MV, and oxypurinol administration inhibited this activity and provided protection against MV-induced oxidative stress and contractile dysfunction. Specifically, oxypurinol treatment partially attenuated both protein oxidation and lipid peroxidation in the diaphragm during MV. Further, XO inhibition retarded MV-induced diaphragmatic contractile dysfunction at stimulation frequencies >60 Hz. Collectively, these results suggest that oxidant production by XO contributes to MV-induced oxidative injury and contractile dysfunction in the diaphragm. Nonetheless, the failure of XO inhibition to completely prevent MV-induced diaphragmatic oxidative damage suggests that other sources of oxidant production are active in the diaphragm during prolonged MV. PMID:18974366

  1. 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

  2. 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.

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

    PubMed

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

    2014-07-15

    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.

  4. 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.

  5. Impact of kinetic beds on the incidence of atelectasis in mechanically ventilated patients.

    PubMed

    Chandy, Dipak; Sahityani, Rachna; Aronow, Wilbert S; Khan, Safdar; DeLorenzo, Lawrence J

    2007-01-01

    We investigated the impact of kinetic beds on the incidence of atelectasis in mechanically ventilated patients in an intensive care unit (ICU). All bronchoscopies performed for atelectasis on mechanically ventilated patients between July 2000 and June 2001 and between July 2002 and June 2003 were reviewed. On July 26, 2001, 50 kinetic beds, 20 continuous lateral rotation therapy modules, and 20 percussion and vibration modules were introduced to our institution. Of the 3399 ICU admissions between July 2000 and June 2001, 71 patients developed atelectasis while being mechanically ventilated. Of the 3065 ICU admissions between July 2002 and June 2003, 83 patients developed atelectasis while being mechanically ventilated. Of these, 48 (58%) patients had left-sided atelectasis, 30 (36%) had right-sided atelectasis, and 5 (6%) had bilateral atelectasis. There was no decrease in the incidence of atelectasis in mechanically ventilated patients at our institution after the introduction of kinetic beds and vibration, percussion, and rotation modules despite their widespread availability.

  6. Adaptive mechanical backup ventilation for preterm infants on respiratory assist modes - a pilot study.

    PubMed

    Herber-Jonat, Susanne; Rieger-Fackeldey, Esther; Hummler, Helmut; Schulze, Andreas

    2006-02-01

    Mechanical respiratory-assist modes, such as assist/control, low-rate intermittent mandatory ventilation, continuous positive airway pressure, or proportional assist ventilation (PAV), require a continuous respiratory effort. Because of the frequent occurrence of periodic breathing and/or apnea, mechanical backup ventilation must be initiated during episodes of reduced or absent respiratory drive to maintain gas exchange. The common approach to this problem is a regular conventional mechanical ventilation, which is initiated and withdrawn in an "on/off" function. To develop and evaluate a mechanical backup ventilation mode that is adaptive to the rapidly changing breathing pattern of preterm infants. Prospective randomized clinical crossover trial. Neonatal intensive care unit at the University of Munich, Germany. Preterm infants undergoing PAV. The infants were ventilated with PAV using a newly developed adaptive backup support, with and without pulse-oximetry-guided operation (SpO(2)-sensitive backup). Each infant was ventilated with both modes of backup support on 2 consecutive days, with the sequence randomized. The analysis on 11 preterm infants showed a statistically significant and clinically relevant reduction of the incidence (33%) and duration of oxygen desaturations (52%) when SpO(2)-sensitive adaptive backup support was used. SpO(2)-sensitive adaptive backup proved safe and effective in reducing the incidence and duration of oxygen desaturation in this short-term trial. This technology is potentially applicable to other assisted modalities of ventilation, such as noninvasive nasal ventilation.

  7. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung.

    PubMed

    Lohser, Jens; Slinger, Peter

    2015-08-01

    Lung injury is the leading cause of death after thoracic surgery. Initially recognized after pneumonectomy, it has since been described after any period of 1-lung ventilation (OLV), even in the absence of lung resection. Overhydration and high tidal volumes were thought to be responsible at various points; however, it is now recognized that the pathophysiology is more complex and multifactorial. All causative mechanisms known to trigger ventilator-induced lung injury have been described in the OLV setting. The ventilated lung is exposed to high strain secondary to large, nonphysiologic tidal volumes and loss of the normal functional residual capacity. In addition, the ventilated lung experiences oxidative stress, as well as capillary shear stress because of hyperperfusion. Surgical manipulation and/or resection of the collapsed lung may induce lung injury. Re-expansion of the collapsed lung at the conclusion of OLV invariably induces duration-dependent, ischemia-reperfusion injury. Inflammatory cytokines are released in response to localized injury and may promote local and contralateral lung injury. Protective ventilation and volatile anesthesia lessen the degree of injury; however, increases in biochemical and histologic markers of lung injury appear unavoidable. The endothelial glycocalyx may represent a common pathway for lung injury creation during OLV, because it is damaged by most of the recognized lung injurious mechanisms. Experimental therapies to stabilize the endothelial glycocalyx may afford the ability to reduce lung injury in the future. In the interim, protective ventilation with tidal volumes of 4 to 5 mL/kg predicted body weight, positive end-expiratory pressure of 5 to 10 cm H2O, and routine lung recruitment should be used during OLV in an attempt to minimize harmful lung stress and strain. Additional strategies to reduce lung injury include routine volatile anesthesia and efforts to minimize OLV duration and hyperoxia.

  8. Anaesthesia ventilators

    PubMed Central

    Jain, Rajnish K; Swaminathan, Srinivasan

    2013-01-01

    Anaesthesia ventilators are an integral part of all modern anaesthesia workstations. Automatic ventilators in the operating rooms, which were very simple with few modes of ventilation when introduced, have become very sophisticated with many advanced ventilation modes. Several systems of classification of anaesthesia ventilators exist based upon various parameters. Modern anaesthesia ventilators have either a double circuit, bellow design or a single circuit piston configuration. In the bellows ventilators, ascending bellows design is safer than descending bellows. Piston ventilators have the advantage of delivering accurate tidal volume. They work with electricity as their driving force and do not require a driving gas. To enable improved patient safety, several modifications were done in circle system with the different types of anaesthesia ventilators. Fresh gas decoupling is a modification done in piston ventilators and in descending bellows ventilator to reduce th incidence of ventilator induced volutrauma. In addition to the conventional volume control mode, modern anaesthesia ventilators also provide newer modes of ventilation such as synchronised intermittent mandatory ventilation, pressure-control ventilation and pressure-support ventilation (PSV). PSV mode is particularly useful for patients maintained on spontaneous respiration with laryngeal mask airway. Along with the innumerable benefits provided by these machines, there are various inherent hazards associated with the use of the ventilators in the operating room. To use these workstations safely, it is important for every Anaesthesiologist to have a basic understanding of the mechanics of these ventilators and breathing circuits. PMID:24249886

  9. 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

    2017-08-25

    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, include 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: 1) define the association between pulmonary mechanics (driving pressure, plateau pressure, and compliance) and mortality; and 2) 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 that 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 CONCLUSIONS:: 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.

  10. Non lineal respiratory systems mechanics simulation of acute respiratory distress syndrome during mechanical ventilation.

    PubMed

    Madorno, Matias; Rodriguez, Pablo O

    2010-01-01

    Model and simulation of biological systems help to better understand these systems. In ICUs patients often reach a complex situation where supportive maneuvers require special expertise. Among them, mechanical ventilation in patients suffering from acuter respiratory distress syndrome (ARDS) is specially challenging. This work presents a model which can be simulated and use to help in training of physicians and respiratory therapists to analyze the respiratory mechanics in this kind of patients. We validated the model in 2 ARDS patients.

  11. 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.

  12. Estimates of the demand for mechanical ventilation in the US during an influenza pandemic

    PubMed Central

    Meltzer, Martin I.; Patel, Anita; Koonin, Lisa M.

    2015-01-01

    An outbreak in China in April 2013 of human illnesses due to avian influenza A(H7N9) virus provided reason for U.S. public health officials to revisit existing national pandemic response plans. We built a spreadsheet model to examine the potential demand for invasive mechanical ventilation (excluding “rescue therapy" ventilation). We considered scenarios of either 20% or 30% gross influenza clinical attack rate (CAR), with a “low severity” scenario with case fatality rates (CFR) of 0.05%–0.1%, or a “high severity” scenario (CFR: 0.25%–0.5%). We used rates-of-influenza-related illness to calculate the numbers of potential clinical cases, hospitalizations, admissions to intensive care units (ICUs), and need for mechanical ventilation. We assumed 10 days ventilator use per ventilated patient, 13% of total ventilator demand will occur at peak, and a 33.7% weighted average mortality risk while on a ventilator. At peak, for a 20% CAR, low severity scenario, an additional 7,000 to 11,000 ventilators will be needed, averting a pandemic total of 35,000 to 55,000 deaths. A 30% CAR, high severity scenario, will need approximately 35,000 to 60,500 additional ventilators, averting a pandemic total 178,000 to 308,000 deaths. Estimates of deaths averted may not be realized because successful ventilation also depends on sufficient numbers of suitably trained staff, needed supplies (e.g., drugs, reliable oxygen sources, suction apparatus, circuits, and monitoring equipment) and timely ability to match access to ventilators with critically ill cases. There is a clear challenge to plan and prepare to meet demands for mechanical ventilators for a future severe pandemic. PMID:25878301

  13. Estimates of the demand for mechanical ventilation in the United States during an influenza pandemic.

    PubMed

    Meltzer, Martin I; Patel, Anita; Ajao, Adebola; Nystrom, Scott V; Koonin, Lisa M

    2015-05-01

    An outbreak in China in April 2013 of human illnesses due to avian influenza A(H7N9) virus provided reason for US public health officials to revisit existing national pandemic response plans. We built a spreadsheet model to examine the potential demand for invasive mechanical ventilation (excluding "rescue therapy" ventilation). We considered scenarios of either 20% or 30% gross influenza clinical attack rate (CAR), with a "low severity" scenario with case fatality rates (CFR) of 0.05%-0.1%, or a "high severity" scenario (CFR: 0.25%-0.5%). We used rates-of-influenza-related illness to calculate the numbers of potential clinical cases, hospitalizations, admissions to intensive care units, and need for mechanical ventilation. We assumed 10 days ventilator use per ventilated patient, 13% of total ventilator demand will occur at peak, and a 33.7% weighted average mortality risk while on a ventilator. At peak, for a 20% CAR, low severity scenario, an additional 7000 to 11,000 ventilators will be needed, averting a pandemic total of 35,000 to 55,000 deaths. A 30% CAR, high severity scenario, will need approximately 35,000 to 60,500 additional ventilators, averting a pandemic total 178,000 to 308,000 deaths. Estimates of deaths averted may not be realized because successful ventilation also depends on sufficient numbers of suitably trained staff, needed supplies (eg, drugs, reliable oxygen sources, suction apparatus, circuits, and monitoring equipment) and timely ability to match access to ventilators with critically ill cases. There is a clear challenge to plan and prepare to meet demands for mechanical ventilators for a future severe pandemic.

  14. 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.

  15. 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.

  16. NF-κB Signaling Contributes to Mechanical Ventilation-Induced Diaphragm Weakness

    PubMed Central

    Smuder, Ashley J.; Hudson, Matthew B.; Nelson, W. Bradley; Kavazis, Andreas N.; Powers, Scott K.

    2013-01-01

    Background Although mechanical ventilation (MV) is a life-saving measure for patients in respiratory failure, prolonged MV results in diaphragmatic weakness due to fiber atrophy and contractile dysfunction. Therefore, identifying the signaling pathways responsible for MV-induced diaphragmatic weakness is important. In this context, it is established that oxidative stress is required for MV-induced diaphragmatic weakness to occur. Numerous redox-sensitive signaling pathways exist in muscle including the transcription factor nuclear factor-κB (NF-κB). Although it has been suggested that NF-κB contributes to proteolytic signaling in inactivity-induced atrophy in locomotor muscles, the role that NF-κB plays in MV-induced diaphragmatic weakness is unknown. Objective We tested the hypothesis that NF-κB activation plays a key signaling role in MV-induced diaphragmatic weakness and that oxidative stress is required for NF-κB activation. Design Cause and effect was determined by independently treating mechanically ventilated animals with either a specific NF-κB inhibitor (SN50) or a clinically relevant antioxidant (curcumin). Measurements and Main Results Inhibition of NF-κB activity partially attenuated both MV-induced diaphragmatic atrophy and contractile dysfunction. Further, treatment with the antioxidant curcumin prevented MV-induced activation of NF-κB in the diaphragm and rescued the diaphragm from both MV-induced atrophy and contractile dysfunction. Conclusions Collectively, these findings support the hypothesis that NF-κB activation plays a significant signaling role in MV-induced diaphragmatic weakness and that oxidative stress is an upstream activator of NF-κB. Finally, our results suggest that prevention of MV-induced oxidative stress in the diaphragm could be a useful clinical strategy to prevent or delay MV-induced diaphragmatic weakness. PMID:22080641

  17. [Neurally adjusted ventilatory assist: a revolution of mechanical ventilation?].

    PubMed

    Piquilloud, Lise; Jolliet, Philippe; Tassaux, Didier

    2010-12-15

    Neurally adjusted ventilatory assist or NAVA is a new assisted ventilatory mode which, in comparison with pressure support, leads to improved patient-ventilator synchrony and a more variable ventilatory pattern. It also improves arterial oxygenation. With NAVA, the electrical activity of the diaphragm is recorded through a nasogastric tube equipped with electrodes. This electrical activity is then used to pilot the ventilator. With NAVA, the patient's respiratory pattern controls the ventilator's timing of triggering and cycling as well as the magnitude of pressurization, which is proportional to inspiratory demand. The effect of NAVA on patient outcome remains to be determined through well-designed prospective studies.

  18. Oxidative stress is required for mechanical ventilation-induced protease activation in the diaphragm

    PubMed Central

    Smuder, Ashley J.; Wu, Min; Hudson, Matthew B.; Nelson, W. Bradley; Powers, Scott K.

    2010-01-01

    Prolonged mechanical ventilation (MV) results in diaphragmatic weakness due to fiber atrophy and contractile dysfunction. Recent work reveals that activation of the proteases calpain and caspase-3 is required for MV-induced diaphragmatic atrophy and contractile dysfunction. However, the mechanism(s) responsible for activation of these proteases remains unknown. To address this issue, we tested the hypothesis that oxidative stress is essential for the activation of calpain and caspase-3 in the diaphragm during MV. Cause-and-effect was established by prevention of MV-induced diaphragmatic oxidative stress using the antioxidant Trolox. Treatment of animals with Trolox prevented MV-induced protein oxidation and lipid peroxidation in the diaphragm. Importantly, the Trolox-mediated protection from MV-induced oxidative stress prevented the activation of calpain and caspase-3 in the diaphragm during MV. Furthermore, the avoidance of MV-induced oxidative stress not only averted the activation of these proteases but also rescued the diaphragm from MV-induced diaphragmatic myofiber atrophy and contractile dysfunction. Collectively, these findings support the prediction that oxidative stress is required for MV-induced activation of calpain and caspase-3 in the diaphragm and are consistent with the concept that antioxidant therapy can retard MV-induced diaphragmatic weakness. PMID:20203072

  19. Differences in the prognosis among severe trauma and medical patients requiring mechanical ventilation.

    PubMed

    Santana-Cabrera, Luciano; Sánchez-Palacios, Manuel; Rodríguez, Alina Uriarte

    2013-01-01

    Objetive. To find the differences between the prognosis of the patients with severe traumatism injury and those who were admitted with medical pathology who also required mechanical ventilation in our ICU. Patients and Method. Retrospective descriptive study in a polyvalent ICU of a third level hospital for a period of 8 years. Epidemiological variables such as age, sex, average stay, mortality, APACHE II at admission and days of mechanical ventilation, were analyzed in patients with severe traumatism injury and patients with medical pathology that were admitted in ICU and received mechanical ventilation during this period. Results. During the study period were admitted 208 patients with severe traumatism injury and 732 medical patients, all of them required mechanical ventilation. Patients with severe traumatism injury are more younger (41.8 vs 55.3 years, p = 0.001) and entered ICU in a state of minor severity, according to the prognostic index APACHE II (14.8 vs 17.4, p < 0.001), despite which they required more days of mechanical ventilation (9.8 vs 7.8 days, p = 0.017) and had a higher average stay (11.4 vs 9.4 days, p = 0.027), although the mortality was significantly lower (38.2% vs 28.2%, p = 0.005). Multivariate analysis showed as independent variables associated with mortality, the APACHE II (p < 0.0001), the average stay in ICU (p < 0.0001), days of mechanical ventilation (p < 0.0001) and type patient (p = 0.016). Conclusions. Patients with severe traumatic injury that require mechanical ventilation despite to be admitted in ICU in a state of greater severity, having an increased ICU stay and more days of mechanical ventilation, have a better prognosis than medical patients that required also mechanical ventilation at ICU stay, likely to be younger.

  20. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children.

    PubMed

    Rose, Louise; Schultz, Marcus J; Cardwell, Chris R; Jouvet, Philippe; McAuley, Danny F; Blackwood, Bronagh

    2014-06-10

    an ICU. Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I(2) = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk. Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for

  1. 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

    2017-02-10

    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 PCO2. 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 PCO2 normalised arterial pH in the face of metabolic acidosis.

  2. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis

    PubMed Central

    Ruest, Annie; Meade, Maureen O; Cook, Deborah J

    2007-01-01

    Objective To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults. Design Systematic review and meta-analysis. Data sources Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty. Review methods Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis. Results 11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit. Conclusions Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit. PMID:17387118

  3. Opioid Analgesia in Mechanically Ventilated Children: Results from the multicenter MOTIF study

    PubMed Central

    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

    Objective To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the Pediatric Intensive Care Unit (PICU). Design Prospective, observational study with 100% accrual of eligible patients. Setting Seven PICUs from tertiary-care children’s hospitals in the Collaborative Pediatric Critical Care Research Network. Patients 419 children treated with morphine or fentanyl infusions. Interventions None Measurements and Main Results 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%CI: 12–19%) and 20% patients (95%CI: 16–24%) respectively. Among patients receiving opioids for longer than 3 days (n=225), this occurred in 28% (95%CI 22–33%) and 35% (95%CI 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 (OR 7.9, 95%CI 4.3–14.3; p<0.001) or co-therapy with midazolam (OR 5.6, 95%CI 2.4–12.9; p<0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (OR 0.48, 95%CI 0.25–0.92; p=0.03), for patients receiving higher initial doses (OR 0.96, 95%CI 0.95–0.98; p<0.001), or if patients had prior PICU admissions (OR 0.37, 95%CI 0.15–0.89, p=0.03). Conclusions 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 opioid therapy. PMID:23132396

  4. Evaluation of an Incremental Ventilation Energy Model for Estimating Impacts of Air Sealing and Mechanical Ventilation

    SciTech Connect

    Logue, Jennifer M.; Turner, Willliam JN; Walker, Iain S.; Singer, Brett C.

    2012-07-01

    Changing the rate of airflow through a home affects the annual thermal conditioning energy. Large-scale changes to airflow rates of the housing stock can significantly alter the energy consumption of the residential energy sector. However, the complexity of existing residential energy models hampers the ability to estimate the impact of policy changes on a state or nationwide level. The Incremental Ventilation Energy (IVE) model developed in this study was designed to combine the output of simple airflow models and a limited set of home characteristics to estimate the associated change in energy demand of homes. The IVE model was designed specifically to enable modelers to use existing databases of home characteristics to determine the impact of policy on ventilation at a population scale. In this report, we describe the IVE model and demonstrate that its estimates of energy change are comparable to the estimates of a wellvalidated, complex residential energy model when applied to homes with limited parameterization. Homes with extensive parameterization would be more accurately characterized by complex residential energy models. The demonstration included a range of home types, climates, and ventilation systems that cover a large fraction of the residential housing sector.

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

    SciTech Connect

    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, and 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.

  6. Mechanical ventilation with the esophageal tracheal combitube (ETC) in the intensive care unit.

    PubMed Central

    Frass, M; Frenzer, R; Mayer, G; Popovic, R; Leithner, C

    1987-01-01

    Mechanical ventilation in critically ill patients is usually performed with the conventional endotracheal airway. The esophageal tracheal combitube (ETC) is a new device for cardiopulmonary resuscitation, conceived to bridge the gap between hospital and prehospital phases. The ETC may be used in esophageal and endotracheal positions. The authors report six patients who were ventilated with the ETC in the esophageal obturator position for 2-8 h after emergency ventilation. Blood gas data showed adequate ventilation with the ETC during the observation period. Data suggest that mechanical ventilation with the ETC is possible for several hours after cardiopulmonary resuscitation. This might be helpful during the initial post-arrest period, when replacement of the ETC by a conventional endotracheal airway might destabilize a vulnerable patient. PMID:3440049

  7. Characteristics and progression of children with acute viral bronchiolitis subjected to mechanical ventilation

    PubMed Central

    Ferlini, Roberta; Pinheiro, Flávia Ohlweiler; Andreolio, Cinara; Carvalho, Paulo Roberto Antonacci; Piva, Jefferson Pedro

    2016-01-01

    Objective To analyze the characteristics of children with acute viral bronchiolitis subjected to mechanical ventilation for three consecutive years and to correlate their progression with mechanical ventilation parameters and fluid balance. Methods Longitudinal study of a series of infants (< one year old) subjected to mechanical ventilation for acute viral bronchitis from January 2012 to September 2014 in the pediatric intensive care unit. The children's clinical records were reviewed, and their anthropometric data, mechanical ventilation parameters, fluid balance, clinical progression, and major complications were recorded. Results Sixty-six infants (3.0 ± 2.0 months old and with an average weight of 4.7 ± 1.4kg) were included, of whom 62% were boys; a virus was identified in 86%. The average duration of mechanical ventilation was 6.5 ± 2.9 days, and the average length of stay in the pediatric intensive care unit was 9.1 ± 3.5 days; the mortality rate was 1.5% (1/66). The peak inspiratory pressure remained at 30cmH2O during the first four days of mechanical ventilation and then decreased before extubation (25 cmH2O; p < 0.05). Pneumothorax occurred in 10% of the sample and extubation failure in 9%, which was due to upper airway obstruction in half of the cases. The cumulative fluid balance on mechanical ventilation day four was 402 ± 254mL, which corresponds to an increase of 9.0 ± 5.9% in body weight. Thirty-seven patients (56%) exhibited a weight gain of 10% or more, which was not significantly associated with the ventilation parameters on mechanical ventilation day four, extubation failure, duration of mechanical ventilation or length of stay in the pediatric intensive care unit. Conclusion The rate of mechanical ventilation for acute viral bronchiolitis remains constant, being associated with low mortality, few adverse effects, and positive cumulative fluid balance during the first days. Better fluid control might reduce the duration of mechanical

  8. 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.

  9. 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.

  10. Transpulmonary pressure monitoring during mechanical ventilation: a bench-to-bedside review.

    PubMed

    Mietto, Cristina; Malbrain, Manu L N G; Chiumello, Davide

    2015-01-01

    Different ventilation strategies have been suggested in the past in patients with acute respiratory distress syndrome (ARDS). Airway pressure monitoring alone is inadequate to assure optimal ventilatory support in ARDS patients. The assessment of transpulmonary pressure (PTP) can help clinicians to tailor mechanical ventilation to the individual patient needs. Transpulmonary pressure monitoring, defined as airway pressure (Paw) minus intrathoracic pressure (ITP), provides essential information about chest wall mechanics and its effects on the respiratory system and lung mechanics. The positioning of an esophageal catheter is required to measure the esophageal pressure (Peso), which is clinically used as a surrogate for ITP or pleural pressure (Ppl), and calculates the transpulmonary pressure. The benefits of such a ventilation approach are avoiding excessive lung stress and individualizing the positive end-expiratory pressure (PEEP) setting. The aim is to prevent over-distention of alveoli and the cyclic recruitment/derecruitment or shear stress of lung parenchyma, mechanisms associated with ventilator-induced lung injury (VILI). Knowledge of the real lung distending pressure, i.e. the transpulmonary pressure, has shown to be useful in both controlled and assisted mechanical ventilation. In the latter ventilator modes, Peso measurement allows one to assess a patient's respiratory effort, patient-ventilator asynchrony, intrinsic PEEP and the calculation of work of breathing. Conditions that have an impact on Peso, such as abdominal hypertension, will also be discussed briefly.

  11. Core competency in mechanical ventilation: development of educational objectives using the Delphi technique.

    PubMed

    Goligher, Ewan C; Ferguson, Niall D; Kenny, Lisa P

    2012-10-01

    We sought to identify and standardize the core clinical knowledge and skills required to care for patients receiving mechanical ventilation. Prospective survey reaching consensus by the Delphi technique. North American survey conducted anonymously by electronic e-mail. International experts in mechanical ventilation, frontline resident educators, medical education experts, and community intensivists were recruited to participate Fourteen panelists participated (ten content experts, three resident educators, one medical education expert, zero community intensivists). Individual panelists generated a total of 200 educational objectives, of which 109 were duplicates. Of the remaining 91 items, 56 met predefined consensus criteria for inclusion in the final set of educational objectives. The educational objectives spanned a broad range of categories, including respiratory physiology, noninvasive ventilation, lung protective ventilation, weaning, and withholding and withdrawing mechanical ventilation. Agreement among panelists on the items included was high (median proportion supporting item inclusion was 88%, range 70%-100%). There is a consensus that general resident core competency in mechanical ventilation requires a broad range of knowledge application and skill. These educational objectives may help identify and standardize the educational outcomes related to mechanical ventilation that residents should achieve.

  12. Gas exchange measurement during pediatric mechanical ventilation--agreement between gas sampling at the airway and the ventilator exhaust.

    PubMed

    Smallwood, Craig D; Mehta, Nilesh M

    2013-12-01

    A variety of indirect calorimetry (IC) devices are used for gas exchange measurement and calculation of resting energy expenditure (REE) in the pediatric intensive care unit. The aim of this investigation was to compare oxygen consumption (VO2), carbon dioxide elimination (VCO2), REE and respiratory quotient (RQ) in mechanically ventilated children, obtained by 2 devices using distinct gas sampling methods. Mechanically ventilated children were targeted for IC and gas exchange measurements were recorded for a 30 min period, simultaneously using the E-COVX(®) (gas sampling at the airway) and the Vmax(®) (gas sampling at the humidifier and ventilator exhaust). Steady state gas exchange measurements by the 2 devices were tested for agreement using Spearman correlation and Bland-Altman analysis. Steady state data from both devices were available in 19 tests and were included in the analysis. The correlations coefficients for measurements by the 2 devices were r = 0.903(P < 0.001), 0.955(P < 0.001), 0.944(P < 0.001) and 0.484(P < 0.05) for VO2, VCO2, REE and RQ, respectively. The mean percentage bias (limits of agreement) for VO2, VCO2, REE and RQ values between the two methods (Vmax-E-COVX) was 0.2 (-41.8-42.3), -0.8 (-21.8-20.1), -2.2 (-33.9-29.6) and 1.9 (-21-24.9) respectively. Despite strong correlations and small mean biases for VO2, VCO2 and REE obtained by the Vmax(®) and E-COVX(®), the limits of agreement were beyond the clinically acceptable range. These devices should not be used interchangeably for gas exchange measurements in mechanically ventilated children. Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

  13. Relationship between airway narrowing, patchy ventilation and lung mechanics in asthmatics.

    PubMed

    Tgavalekos, N T; Musch, G; Harris, R S; Vidal Melo, M F; Winkler, T; Schroeder, T; Callahan, R; Lutchen, K R; Venegas, J G

    2007-06-01

    Bronchoconstriction in asthma results in patchy ventilation forming ventilation defects (VDefs). Patchy ventilation is clinically important because it affects obstructive symptoms and impairs both gas exchange and the distribution of inhaled medications. The current study combined functional imaging, oscillatory mechanics and theoretical modelling to test whether the degrees of constriction of airways feeding those units outside VDefs were related to the extent of VDefs in bronchoconstricted asthmatic subjects. Positron emission tomography was used to quantify the regional distribution of ventilation and oscillatory mechanics were measured in asthmatic subjects before and after bronchoconstriction. For each subject, ventilation data was mapped into an anatomically based lung model that was used to evaluate whether airway constriction patterns, consistent with the imaging data, were capable of matching the measured changes in airflow obstruction. The degree and heterogeneity of constriction of the airways feeding alveolar units outside VDefs was similar among the subjects studied despite large inter-subject variability in airflow obstruction and the extent of the ventilation defects. Analysis of the data amongst the subjects showed an inverse relationship between the reduction in mean airway conductance, measured in the breathing frequency range during bronchoconstriction, and the fraction of lung involved in ventilation defects. The current data supports the concept that patchy ventilation is an expression of the integrated system and not just the sum of independent responses of individual airways.

  14. Physiological responses to passive exercise in adults receiving mechanical ventilation.

    PubMed

    Amidei, Christina; Sole, Mary Lou

    2013-07-01

    Critical illness may weaken muscles, with long-term consequences. To assess physiological responses to an early standardized passive exercise protocol to prevent muscle weakness in adults receiving mechanical ventilation. A quasi-experimental within-subjects repeated-measures design was used. Within 72 hours of intubation, 30 patients had 20 minutes of bilateral passive leg movement delivered by continuous-passive-motion machines at a standardized rate and flexion-extension. Heart rate, mean blood pressure, oxygen saturation, and cytokine levels were measured before, during, and after the intervention. The Behavioral Pain Scale was used to measure patients' comfort. Repeated-measures analysis of variance was used to analyze the effect of the exercise on independent variables. Patients were mostly white men with a mean age of 56.5 years (SD, 16.9) with moderate mortality risk and illness severity. Heart rate, mean blood pressure, and oxygen saturation did not differ from baseline at any time measured. Pain scores were significantly reduced (F(2.43,70.42) = 4.08; P = .02) 5 and 10 minutes after exercise started and remained reduced at the end of exercise and 1 hour later. Interleukin 6 levels were significantly reduced (F(1.60,43.1) = 4.35; P = .03) at the end of exercise but not after the final rest period. Interleukin 10 levels did not differ significantly. Ratios of interleukin 6 to interleukin 10 decreased significantly (F(1.61,43.38) = 3.42; P = .05) at the end of exercise and again after 60 minutes' rest. The exercise was well tolerated, and comfort improved during and after the intervention. Cytokine levels provided physiological rationale for benefits of early exercise.

  15. The use of mechanical ventilation protocols in Canadian neonatal intensive care units

    PubMed Central

    Shalish, Wissam; Anna, Guilherme Mendes Sant’

    2015-01-01

    OBJECTIVES: To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols. METHODS: A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013. RESULTS: Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]). CONCLUSION: Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes. PMID:26038643

  16. Respiratory mechanics measured by forced oscillations during mechanical ventilation through a tracheal tube.

    PubMed

    Scholz, Alexander-Wigbert; Weiler, Norbert; David, Matthias; Markstaller, Klaus

    2011-05-01

    The forced oscillation technique (FOT) allows the measurement of respiratory mechanics in the intensive care setting. The aim of this study was to compare the FOT with a reference method during mechanical ventilation through a tracheal tube. The respiratory impedance spectra were measured by FOT in nine anaesthetized pigs, and resistance and compliance were estimated on the basis of a linear resistance-compliance inertance model. In comparison, resistance and compliance were quantified by the multiple linear regression analysis (LSF) of conventional ventilator waveforms to the equation of motion. The resistance of the sample was found to range from 6 to 21 cmH(2)O s l(-1) and the compliance from 12 to 32 ml cmH(2)O(-1). A Bland-Altman analysis of the resistance resulted in a sufficient agreement (bias -0.4 cmH(2)O s l(-1); standard deviation of differences 1.4 cmH(2)O s l(-1); correlation coefficient 0.93) and test-retest reliability (coefficient of variation of repeated measurements: FOT 2.1%; LSF 1.9%). The compliance, however, was poor in agreement (bias -8 ml cmH(2)O(-1), standard deviation of differences 7 ml cmH(2)O(-1), correlation coefficient 0.74) and repeatability (coefficient of variation: FOT 23%; LSF 1.7%). In conclusion, FOT provides an alternative for monitoring resistance, but not compliance, in tracheally intubated and ventilated subjects.

  17. MEASUREMENT OF AMMONIA EMISSIONS FROM MECHANICALLY VENTILATED POULTRY HOUSES USING MULTIPATH TUNABLE DIODE LASER SPECTROSCOPY

    EPA Science Inventory

    Ammonia emissions from mechanically ventilated poultry operations are an important environmental concern. Open Path Tunable Diode Laser Absorption Spectroscopy has emerged as a robust real-time method for gas phase measurement of ammonia concentrations in agricultural settings. ...

  18. MEASUREMENT OF AMMONIA EMISSIONS FROM MECHANICALLY VENTILATED POULTRY HOUSES USING MULTIPATH TUNABLE DIODE LASER SPECTROSCOPY

    EPA Science Inventory

    Ammonia emissions from mechanically ventilated poultry operations are an important environmental concern. Open Path Tunable Diode Laser Absorption Spectroscopy has emerged as a robust real-time method for gas phase measurement of ammonia concentrations in agricultural settings. ...

  19. Mechanical ventilation and sepsis impair protein metabolism in the diaphragm of neonatal pigs

    USDA-ARS?s Scientific Manuscript database

    Mechanical ventilation (MV) impairs diaphragmatic function and diminishes the ability to wean from ventilatory support in adult humans. In normal neonatal pigs, animals that are highly anabolic, endotoxin (LPS) infusion induces sepsis, reduces peripheral skeletal muscle protein synthesis rates, but ...

  20. Myocardial perfusion as assessed by thallium-201 scintigraphy during the discontinuation of mechanical ventilation in ventilator-dependent patients

    SciTech Connect

    Hurford, W.E.; Lynch, K.E.; Strauss, H.W.; Lowenstein, E.; Zapol, W.M. )

    1991-06-01

    Patients who cannot be separated from mechanical ventilation (MV) after an episode of acute respiratory failure often have coexisting coronary artery disease. The authors hypothesized that increased left ventricular (LV) wall stress during periods of spontaneous ventilation (SV) could alter myocardial perfusion in these patients. Using thallium-201 (201TI) myocardial scintigraphy, the authors studied the occurrence of myocardial perfusion abnormalities during periods of SV in 15 MV-dependent patients (nine women, six men; aged 71 {plus minus} 7 yr, mean {plus minus} SD). Fourteen of these patients were studied once with 201TI myocardial scintigraphy during intermittent mechanical ventilation (IMV) and again on another day, after at least 10 min of SV through a T-piece. One patient was studied during SV only. Thirteen of 14 of the patients (93%) studied during MV had abnormal patterns of initial myocardial 201TI uptake, but only 1 patient demonstrated redistribution of 201TI on delayed images. The remainder of the abnormalities observed during MV were fixed defects. SV produced significant alterations of myocardial 201TI distribution or transient LV dilation, or both, in 7 of the 15 patients (47%). Four patients demonstrated new regional decreases of LV myocardial thallium concentration with redistribution of the isotope on delayed images. The patient studied only during SV also had myocardial 201TI defects with redistribution. Five patients (3 also having areas of 201TI redistribution) had transient LV dilation during SV.

  1. Surgery for Cerebellar Hemorrhage: A National Surgical Quality Improvement Program Database Analysis of Patient Outcomes and Factors Associated with 30-Day Mortality and Prolonged Ventilation.

    PubMed

    Arnone, Gregory D; Esfahani, Darian R; Wonais, Matt; Kumar, Prateek; Scheer, Justin K; Alaraj, Ali; Amin-Hanjani, Sepideh; Charbel, Fady T; Mehta, Ankit I

    2017-10-01

    Primary cerebellar hemorrhage accounts for 10% of all intracranial hemorrhages. Given the confined space of the posterior fossa, cerebellar hemorrhage management sometimes necessitates suboccipital decompression and hematoma evacuation. In this study, we examine outcomes after surgery for primary cerebellar hemorrhage and identify risk factors associated with adverse outcomes. A retrospective review of the 2005-2014 American College of Surgeons-National Surgical Quality Improvement Program database was performed, with Current Procedural Terminology Code 61315 (suboccipital craniectomy or craniotomy for evacuation of cerebellar hemorrhage) queried between 2005 and 2014. Patient demographics, preoperative comorbidities, and 30-day outcomes were analyzed. Univariate and multivariate regression analyses were performed to identify predictors of mortality and adverse events. A total of 158 craniotomies were studied, with a 30-day mortality rate of 26.6%. The most common adverse events included ventilator dependence after 48 hours (48.7%) and pneumonia (24.1%). Almost one quarter (24.7%) of patients required additional operations, with 8.5% of patients undergoing repeat craniotomy. Death was associated with premorbid dependent functional status (P = 0.005), American Society of Anesthesiologists class (P = 0.010), and history of congestive heart failure (P = 0.031). Prolonged ventilation was associated with premorbid functional status (P = 0.043) and ventilator dependence (P = 0.007) before surgery. Cerebellar hemorrhage is associated with significant risk of mortality and ventilator dependence. In patients who require surgery, 30-day mortality risk remains high (26.6%), with functional status and American Society of Anesthesiologists class predictive of death. Copyright © 2017 Elsevier Inc. All rights reserved.

  2. Online estimation of respiratory mechanics in non-invasive pressure support ventilation: a bench model study.

    PubMed

    Mulqueeny, Qestra; Tassaux, Didier; Vignaux, Laurence; Jolliet, Philippe; Schindhelm, Klaus; Redmond, Stephen; Lovell, Nigel H

    2010-01-01

    An online algorithm for determining respiratory mechanics in patients using non-invasive ventilation (NIV) in pressure support mode was developed and embedded in a ventilator system. Based on multiple linear regression (MLR) of respiratory data, the algorithm was tested on a patient bench model under conditions with and without leak and simulating a variety of mechanics. Bland-Altman analysis indicates reliable measures of compliance across the clinical range of interest (± 11-18% limits of agreement). Resistance measures showed large quantitative errors (30-50%), however, it was still possible to qualitatively distinguish between normal and obstructive resistances. This outcome provides clinically significant information for ventilator titration and patient management.

  3. Effects of a 1:1 inspiratory to expiratory ratio on respiratory mechanics and oxygenation during one-lung ventilation in the lateral decubitus position.

    PubMed

    Kim, S H; Choi, Y S; Lee, J G; Park, I H; Oh, Y J

    2012-11-01

    Prolonged inspiratory to expiratory (I:E) ratio ventilation may have both positive and negative effects on respiratory mechanics and oxygenation during one-lung ventilation (OLV), but definitive information is currently lacking. We therefore compared the effects of volume-controlled ventilation with I:E ratios of 1:1 and 1:2 on respiratory mechanics and oxygenation during OLV. Fifty-six patients undergoing thoracoscopic lobectomy were randomly assigned volume-controlled ventilation with an I:E ratio of 1:1 (group 1:1, n=28) or 1:2 (group 1:2, n=28) during OLV. Arterial and central venous blood gas analyses and respiratory variables were recorded 15 minutes into two-lung ventilation, at 30 and 60 minutes during OLV, and 15 minutes after two-lung ventilation was re-initiated. Peak and plateau airway pressures in cmH2O [standard deviation] during OLV were significantly lower in group 1:1 than in group 1:2 (P <0.01) (19 [3] and 23 [4]; 16 [3] and 19 [5], respectively). The arterial to end-tidal carbon dioxide tension difference was significantly lower in group 1:1 than in group 1:2 (P <0.01), (0.5 [0.3] and 1.1 [0.5]). There were no significant differences in PaO2 during OLV between the two groups (OLV30, P=0.856; OLV60, P=0.473). In summary, volume-controlled ventilation with an I:E ratio of 1:1 reduced peak and plateau airway pressures improved dynamic compliance and efficiency of alveolar ventilation, but it did not improve arterial oxygenation in a substantial manner. Furthermore, the associated increase in mean airway pressure might have reduced cardiac output, resulting in a lower central venous oxygen saturation.

  4. Risk factors relating to the need for mechanical ventilation in isolated cervical spinal cord injury patients.

    PubMed

    Lertudomphonwanit, Thamrong; Wattanaapisit, Thanet; Chavasiri, Cholavech; Chotivichit, Areesak

    2014-09-01

    Cervical spinal cord injuries (SCI) are a major public health problem. Respiratory complications are among the most important causes of morbidity and mortality in patients with cervical SCI, especially respiratory failure. Based on our evaluation of the existing English language literature, few previous studies appear to have reported on risk factors associated with the need for mechanical ventilation in isolated cervical SCI patients who had no concomitant injuries or diseases at the time ofadmission. The purpose of this study was to determine incidence and riskfactors relating to the needfor mechanical ventilation in isolated cervical spinal cord injury (SCI) patients who had no concomitant injuries. This retrospective study was conducted by reviewing and analyzing the patient data of 66 isolated cervical-SCI patients who were admitted in our hospital between January 1995 andDecember 2009. Patient medical records were reviewed for demographic data, neurological injuries, needfor mechanical ventilation, definitive treatment, complications, and outcomes. Univariate and multivariate analysis were used to identify predisposing risk factors relating to patient dependency on mechanical ventilation. Of the 66patients, 30.3% (20/66) required mechanical ventilation and 22.7% (15/66) were identified as complete cord injury, ofwhich seven sustained injury above CS. Of the patients with complete SCI, 66.7% (10/15) were dependent on mechanical ventilation, as were 85% (6/7) with SCI above C5. All five of the patients with complete-SCI above C5 who received operative treatment were dependent upon mechanical ventilation, postoperatively. Only 19.6% (10/51) of the incomplete injury group required mechanical ventilation. Univariate analysis indicated the following factors as significantly increasing the risk ofventilator dependence: complete SCI (p = 0.001), SCI above C5 level (p = 0.011) and operative treatment (p = 0.008). Multivariate analysis identified the following factors

  5. Assisted Ventilation.

    PubMed

    Dries, David J

    2016-01-01

    Controlled Mechanical Ventilation may be essential in the setting of severe respiratory failure but consequences to the patient including increased use of sedation and neuromuscular blockade may contribute to delirium, atelectasis, and diaphragm dysfunction. Assisted ventilation allows spontaneous breathing activity to restore physiological displacement of the diaphragm and recruit better perfused lung regions. Pressure Support Ventilation is the most frequently used mode of assisted mechanical ventilation. However, this mode continues to provide a monotonous pattern of support for respiration which is normally a dynamic process. Noisy Pressure Support Ventilation where tidal volume is varied randomly by the ventilator may improve ventilation and perfusion matching but the degree of support is still determined by the ventilator. Two more recent modes of ventilation, Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist (NAVA), allow patient determination of the pattern and depth of ventilation. Proposed advantages of Proportional Assist Ventilation and NAVA include decrease in patient ventilator asynchrony and improved adaptation of ventilator support to changing patient demand. Work of breathing can be normalized with these modes as well. To date, however, a clear pattern of clinical benefit has not been demonstrated. Existing challenges for both of the newer assist modes include monitoring patients with dynamic hyperinflation (auto-positive end expiratory pressure), obstructive lung disease, and air leaks in the ventilator system. NAVA is dependent on consistent transduction of diaphragm activity by an electrode system placed in the esophagus. Longevity of effective support with this technique is unclear.

  6. [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.

  7. Impact of Residential Mechanical Ventilation on Energy Cost and Humidity Control

    SciTech Connect

    Martin, Eric

    2014-01-01

    Optimizing whole house mechanical ventilation as part of the Building Ameerica program's systems engineered approach to constructing housing has been an important subject of the program's research. Ventilation in residential buildings is one component of an effective, comprehensive strategy for creation and maintenance of a comfortable and healthy indoor air environment. The study described in this report is based on building energy modeling with an important focus on the indoor humidity impacts of ventilation. The modeling tools used were EnergyPlus version 7.1 (E+) and EnergyGauge USA (EGUSA). Twelve U.S. cities and five climate zones were represented. A total of 864 simulations (2*2*3*3*12= 864) were run using two building archetypes, two building leakage rates, two building orientations, three ventilation systems, three ventilation rates, and twelve climates.

  8. Impact of Residential Mechanical Ventilation on Energy Cost and Humidity Control

    SciTech Connect

    Martin, E.

    2014-01-01

    The DOE Building America program has been conducting research leading to cost effective high performance homes since the early 1990's. Optimizing whole house mechanical ventilation as part of the program's systems engineered approach to constructing housing has been an important subject of the program's research. Ventilation in residential buildings is one component of an effective, comprehensive strategy for creation and maintenance of a comfortable and healthy indoor air environment. The study described in this white paper is based on building energy modeling with an important focus on the indoor humidity impacts of ventilation. The modeling tools used were EnergyPlus version 7.1 (E+) and EnergyGauge USA (EGUSA). Twelve U.S. cities and five climate zones were represented. A total of 864 simulations (2*2*3*3*12= 864) were run using two building archetypes, two building leakage rates, two building orientations, three ventilation systems, three ventilation rates, and twelve climates.

  9. Impact of the prolonged slow expiratory maneuver on respiratory mechanics in wheezing infants.

    PubMed

    Lanza, Fernanda de Cordoba; Wandalsen, Gustavo Falbo; Cruz, Carolina Lopes da; Solé, Dirceu

    2013-01-01

    To evaluate changes in respiratory mechanics and tidal volume (V T) in wheezing infants in spontaneous ventilation after performing the technique known as the prolonged, slow expiratory (PSE) maneuver. We included infants with a history of recurrent wheezing and who had had no exacerbations in the previous 15 days. For the assessment of the pulmonary function, the infants were sedated and placed in the supine position, and a face mask was used and connected to a pneumotachograph. The variables of tidal breathing (V T and RR) as well as those of respiratory mechanics-respiratory system compliance (Crs), respiratory system resistance (Rrs), and the respiratory system time constant (prs)-were measured before and after three consecutive PSE maneuvers. We evaluated 18 infants. The mean age was 32 ± 11 weeks. After PSE, there was a significant increase in V T (79.3 ± 15.6 mL vs. 85.7 ± 17.2 mL; p = 0.009) and a significant decrease in RR (40.6 ± 6.9 breaths/min vs. 38.8 ± 0,9 breaths/min; p = 0.042). However, no significant differences were found in the variables of respiratory mechanics (Crs: 11.0 ± 3.1 mL/cmH2O vs. 11.3 ± 2.7 mL/cmH2O; Rrs: 29.9 ± 6.2 cmH2O • mL-1 • s-1 vs. 30.8 ± 7.1 cmH2O • mL-1 • s-1; and prs: 0.32 ± 0.11 s vs. 0.34 ±0.12 s; p > 0.05 for all). This respiratory therapy technique is able to induce significant changes in V T and RR in infants with recurrent wheezing, even in the absence of exacerbations. The fact that the variables related to respiratory mechanics remained unchanged indicates that the technique is safe to apply in this group of patients. Studies involving symptomatic infants are needed in order to quantify the functional effects of the technique.

  10. Impact of the prolonged slow expiratory maneuver on respiratory mechanics in wheezing infants *

    PubMed Central

    Lanza, Fernanda de Cordoba; Wandalsen, Gustavo Falbo; da Cruz, Carolina Lopes; Solé, Dirceu

    2013-01-01

    OBJECTIVE: To evaluate changes in respiratory mechanics and tidal volume (VT) in wheezing infants in spontaneous ventilation after performing the technique known as the prolonged, slow expiratory (PSE) maneuver. METHODS: We included infants with a history of recurrent wheezing and who had had no exacerbations in the previous 15 days. For the assessment of the pulmonary function, the infants were sedated and placed in the supine position, and a face mask was used and connected to a pneumotachograph. The variables of tidal breathing (VT and RR) as well as those of respiratory mechanics-respiratory system compliance (Crs), respiratory system resistance (Rrs), and the respiratory system time constant (prs)-were measured before and after three consecutive PSE maneuvers. RESULTS: We evaluated 18 infants. The mean age was 32 ± 11 weeks. After PSE, there was a significant increase in VT (79.3 ± 15.6 mL vs. 85.7 ± 17.2 mL; p = 0.009) and a significant decrease in RR (40.6 ± 6.9 breaths/min vs. 38.8 ± 0,9 breaths/min; p = 0.042). However, no significant differences were found in the variables of respiratory mechanics (Crs: 11.0 ± 3.1 mL/cmH2O vs. 11.3 ± 2.7 mL/cmH2O; Rrs: 29.9 ± 6.2 cmH2O • mL−1 • s−1 vs. 30.8 ± 7.1 cmH2O • mL−1 • s−1; and prs: 0.32 ± 0.11 s vs. 0.34 ±0.12 s; p > 0.05 for all). CONCLUSIONS: This respiratory therapy technique is able to induce significant changes in VT and RR in infants with recurrent wheezing, even in the absence of exacerbations. The fact that the variables related to respiratory mechanics remained unchanged indicates that the technique is safe to apply in this group of patients. Studies involving symptomatic infants are needed in order to quantify the functional effects of the technique. PMID:23503488

  11. Epileptogenesis provoked by prolonged experimental febrile seizures: mechanisms and biomarkers

    PubMed Central

    Dubé, Celiné M.; Ravizza, Teresa; Hamamura, Mark; Zha, Qinqin; Keebaugh, Andrew; Fok, Kimberly; Andres, Adrienne M.; Nalcioglu, Orhan; Obenaus, Andre; Vezzani, Annamaria; Baram, Tallie Z.

    2010-01-01

    Whether long febrile seizures (FS) can cause epilepsy in the absence of genetic or acquired predisposing factors is unclear. Having established causality between long FS and limbic epilepsy in an animal model, we studied here if the duration of the inciting FS influenced the probability of developing subsequent epilepsy and the severity of the spontaneous seizures. We evaluated if interictal epileptifom activity and/or elevation of hippocampal T2 signal on MRI provided predictive biomarkers for epileptogenesis, and if the inflammatory mediator interleukin-1β (IL-1β), an intrinsic element of FS generation, contributed also to subsequent epileptogenesis. We found that febrile status epilepticus, lasting an average of 64 minutes, increased the severity and duration of subsequent spontaneous seizures compared with FS averaging 24 minutes. Interictal activity in rats sustaining febrile status epilepticus was also significantly longer and more robust, and correlated with the presence of hippocampal T2 changes in individual rats. Neither T2 changes nor interictal activity predicted epileptogenesis. Hippocampal levels of IL-1β were significantly higher for over 24 hours after prolonged FS. Chronically, IL-1β levels were elevated only in rats developing spontaneous limbic seizures after febrile status epilepticus, consistent with a role for this inflammatory mediator in epileptogenesis. Establishing seizure duration as an important determinant in epileptogenesis, and defining the predictive roles of interictal activity, MRI, and inflammatory processes are of paramount importance to the clinical understanding of the outcome of FS, the most common neurological insult in infants and children. PMID:20519523

  12. Mechanics of ventilation in swellsharks, Cephaloscyllium ventriosum (Scyliorhinidae).

    PubMed

    Ferry-Graham, L A

    1999-06-01

    A simple two-pump model has served to describe the mechanics of ventilation in cartilaginous and bony fishes since the pioneering work of G. M. Hughes. A hallmark of this model is that water flow over the gills is continuous. Studies of feeding kinematics in the swellshark Cephaloscyllium ventriosum, however, suggested that a flow reversal occurred during prey capture and transport. Given that feeding is often considered to be simply an exaggeration of the kinematic events performed during respiration, I investigated whether flow reversals are potentially present during respiration. Pressure and impedance data were coupled with kinematic data from high-speed video footage and dye studies and used to infer patterns of water flow through the heads of respiring swellsharks. Swellsharks were implanted with pressure transducers to determine the pattern and magnitude of pressures generated within the buccal and parabranchial (gill) cavities during respiration. Pressure traces revealed extended periods of pressure reversal during the respiratory cycle. Further, impedance data suggested that pressures within the buccal and parabranchial cavities were not generated by the cyclic opening and closing of the jaws and gills in the manner previously suggested by Hughes. Thus, the classic model needs to be re-evaluated to determine its general applicability. Two alternative models for pressure patterns and their mechanism of generation during respiration are provided. The first depicts a double-reversal scenario common in the swellshark whereby pressures are reversed following both of the pump stages (the suction pump and the pressure pump) rather than after the pressure-pump stage only. The second model describes a scenario in which the suction pump is insufficient for generating a positive pressure differential across the gills; thus, a pressure reversal persists throughout this phase of respiration. Kinematic analysis based on high-speed video footage and dye studies, however

  13. Effect of early mobilization on discharge disposition of mechanically ventilated patients

    PubMed Central

    Ota, Hideki; Kawai, Hideki; Sato, Makoto; Ito, Kazuaki; Fujishima, Satoshi; Suzuki, Hiroko

    2015-01-01

    [Purpose] The purpose of this study was to clarify the benefits of early mobilization for mechanically ventilated patients for their survival to discharge to home from the hospital. [Subjects and Methods] Medical records were retrospectively analyzed of patients who satisfied the following criteria: age ≥ 18 years; performance status 0–2 and independent living at their home before admission; mechanical ventilation for more than 48 h; and survival after mechanical ventilation. Mechanically ventilated patients in the early mobilization (EM) group (n = 48) received mobilization therapy, limb exercise and chest physiotherapy, whereas those in the control group (n = 60) received bed rest alone. Univariate and multivariate logistic regression analyses were performed to identify clinical variables associated with discharge disposition. [Results] Early mobilization was a positive independent factor and the presence of neurological deficits was a negative factor contributing to discharge to home. Among patients surviving mechanical ventilation without neurological deficits, the rate of discharge to home was significantly higher among patients in the EM group that in the control group (76% vs. 40%). [Conclusion] Early mobilization can improve the rate of discharge to home of patients requiring mechanical ventilation because of non-neurological deficits. PMID:25931747

  14. Mechanical ventilation in foals with botulism: 9 cases (1989-2002).

    PubMed

    Wilkins, Pamela A; Palmer, Jonathan E

    2003-01-01

    "Shaker foal" disease, toxicoinfectious botulism of foals, was 1st described as a clinical entity in 1967. The reported mortality rate was 90%, with death occurring within 24-72 hours of the onset of the characteristic clinical signs. The mortality rate decreased when equine-origin botulism antitoxin became available; however, a certain percentage of foals continued to die of respiratory failure. Mechanical ventilation is an important part of the treatment of infant botulism and is essential to the survival of many affected infants. We report a retrospective study of 9 foals with toxicoinfectious botulism where early mechanical ventilation was employed as part of the treatment. Foals receiving mechanical ventilation were progressively acidemic and had increased PaCO2 tensions before mechanical ventilation. These arterial blood gas abnormalities were ameliorated with mechanical ventilation. One foal was euthanized for economic reasons; survival in treated foals was 87.5%. Mechanical ventilation of foals with botulism and respiratory failure appears to be an effective therapy.

  15. Infiltration Effects on Residential Pollutant Concentrations for Continuous and Intermittent Mechanical Ventilation Approaches

    SciTech Connect

    Sherman, Max; Logue, Jennifer; Singer, Brett

    2010-06-01

    The prevailing residential ventilation standard in North America, American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 62.2, specifies volumetric airflow requirements as a function of the overall size of the home and the number of bedrooms, assumes a fixed, minimal amount of infiltration, and requires mechanical ventilation to achieve the remainder. The standard allows for infiltration credits and intermittent ventilation patterns that can be shown to provide comparable performance. Whole-house ventilation methods have a substantial effect on time-varying indoor pollutant concentrations. If alternatives specified by Standard 62.2, such as intermittent ventilation, are used, short-term pollutant concentrations could exceed acute health standards even if chronic health standards are met.The authors present a methodology for comparing ASHRAE- and non-ASHRAE-specified ventilation scenarios on relative indoor pollutant concentrations. We use numerical modeling to compare the maximum time-averaged concentrations for acute exposure relevant (1-hour, 8-hour, 24-hour ) and chronic exposure relevant (1-year) time periods for four different ventilation scenarios in six climates with a range of normalized leakage values. The results suggest that long-term concentrations are the most important metric for assessing the effectiveness of whole-house ventilation systems in meeting exposure standards and that, if chronic health exposure standards are met, acute standards will also be met.

  16. Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome

    PubMed Central

    Filho, Roberto R.; Rocha, Leonardo L.; Schultz, Marcus J.

    2014-01-01

    While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called ‘lung-protective’ ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation. PMID:25580269

  17. [Results of an artificial airway management protocol in critical patients subjected to mechanical ventilation].

    PubMed

    Prieto-González, M; López-Messa, J B; Moradillo-González, S; Franzón-Laz, Z M; Ortega-Sáez, M; Poncela-Blanco, M; Alonso-Castañeira, I; Andrés-de Llano, J

    2013-01-01

    To determine the results of the implementation of a protocol in an intensive care unit (ICU) referred to critically ill patients requiring a prolonged artificial airway. A prospective, observational cohort study was carried out. Management strategies were established on the airway by endotracheal intubation (ETI) or tracheostomy, and guidelines were developed for action in the decannulation process. A polyvalent ICU. We studied 169 patients subjected to mechanical ventilation (MV), 67 with ETI ≥ 10 days of MV and 102 with percutaneous (PT) or surgical tracheostomy (TQ). ICU and hospital stays, days of ETI and MV, mortality, tracheostomy, anatomical risk factors, surgical complications, and postoperative decannulation period. ETI versus tracheotomy involved fewer days of MV (17 vs. 30 days, p<0.001), a shorter ICU stay (20 vs. 35 days, p<0.001), and a shorter hospital stay (34 vs. 51 days, p<0.001).There were more TQ procedures in patients with risk factors (47% TP vs. 89% TQ, p<0.001). Intraoperative minor bleeding was the most common complication, being associated with TQ (31% vs. 11%, p = 0.03). TP was associated with a shorter cannulationperiod (25 days vs. 34 days, p<0.04). The protocol variants showed no differences in terms of complications and mortality, when orienting application to patients with similar characteristics. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  18. Remifentanil and propofol for weaning of mechanically ventilated pediatric intensive care patients.

    PubMed

    Welzing, Lars; Vierzig, Anne; Junghaenel, Shino; Eifinger, Frank; Oberthuer, Andre; Trieschmann, Uwe; Roth, Bernhard

    2011-04-01

    Mechanically ventilated pediatric intensive care patients usually receive an analgesic and sedative to keep them comfortable and safe. However, common drugs like fentanyl and midazolam have a long context sensitive half time, resulting in prolonged sedation and an unpredictable extubation time. Children often awake slowly and struggle against the respirator, although their respiratory drive and their airway reflexes are not yet sufficient for extubation. In this pilot study, we replaced fentanyl and midazolam at the final phase of the weaning process with remifentanil and propofol. Twenty-three children aged 3 months-10 years were enrolled. Remifentanil and propofol revealed throughout excellent or good weaning conditions with rapid transition from hypnosis to the development of regular spontaneous breathing, airway protective reflexes, and an appropriate level of alertness. Extubation time following discontinuation of the remifentanil and propofol infusion was only 24 ± 20 min (5-80 min). We conclude that the combination of remifentanil and propofol is a promising option to improve the weaning conditions of pediatric intensive care patients. Randomized controlled trials are needed to compare remifentanil and propofol with conventional weaning protocols.

  19. 46 CFR 154.1205 - Mechanical ventilation system: Standards.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...-ferrous material. (3) The impeller and housing made of austenitic stainless steel. (4) The impeller and housing made of ferrous material with at least 13mm (0.512 in.) tip clearance. (j) No ventilation fan may have any combination of fixed or rotating components made of an aluminum or magnesium alloy and ferrous...

  20. Measured Air Distribution Effectiveness for Residential Mechanical Ventilation Systems

    SciTech Connect

    Sherman, Max; Sherman, Max H.; Walker, Iain S.

    2008-05-01

    The purpose of ventilation is dilute or remove indoor contaminants that an occupant is exposed to. In a multi-zone environment such as a house, there will be different dilution rates and different source strengths in every zone. Most US homes have central HVAC systems, which tend to mix the air thus the indoor conditions between zones. Different types of ventilation systems will provide different amounts of exposure depending on the effectiveness of their air distribution systems and the location of sources and occupants. This paper will report on field measurements using a unique multi-tracer measurement system that has the capacity to measure not only the flow of outdoor air to each zone, but zone-to-zone transport. The paper will derive seven different metrics for the evaluation of air distribution. Measured data from two homes with different levels of natural infiltration will be used to evaluate these metrics for three different ASHRAE Standard 62.2 compliant ventilation systems. Such information can be used to determine the effectiveness of different systems so that appropriate adjustments can be made in residential ventilation standards such as ASHRAE Standard 62.2.

  1. 46 CFR 154.1205 - Mechanical ventilation system: Standards.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...-metallic material that does not generate static electricity. (2) The impeller and housing made of non-ferrous material. (3) The impeller and housing made of austenitic stainless steel. (4) The impeller and housing made of ferrous material with at least 13mm (0.512 in.) tip clearance. (j) No ventilation fan may...

  2. Evaluation of diaphragmatic function in mechanically ventilated children: An ultrasound study.

    PubMed

    Lee, En-Pei; Hsia, Shao-Hsuan; Hsiao, Hsiu-Feng; Chen, Min-Chi; Lin, Jainn-Jim; Chan, Oi-Wa; Lin, Chia-Ying; Yang, Mei-Chin; Liao, Sui-Ling; Lai, Shen-Hao

    2017-01-01

    The recovery of diaphragmatic function is vital for successful extubation from mechanical ventilation. Recent studies have detected diaphragm atrophy in ventilated adults by using ultrasound, but no similar report has been conducted in children. In the current study, we hypothesized that mechanically ventilated children may also develop diaphragm atrophy and diaphragmatic dysfunction. Children who were admitted to the pediatric intensive care unit and were newly intubated for mechanical ventilation were enrolled into this prospective case-control study. Diaphragm ultrasound assessments were performed daily to evaluate diaphragmatic function in the enrolled children until their discharge from the pediatric intensive care unit. Diaphragm thickness and the diaphragmatic thickening fraction (DTF) were measured through these assessments. A total of 31 patients were enrolled, and overall, 1389 ultrasound assessments were performed. Immediately after intubation, the initial diaphragm thickness and DTF were measured to be 1.94 ± 0.44 mm and 25.85% ± 3.29%, respectively. In the first 24 hours of mechanical ventilation, diaphragm thickness and the DTF decreased substantially and decreased gradually thereafter. After extubation, the DTF was significantly different between the successful and failed extubation groups (P < 0.001), and a DTF value of <17% was associated with extubation failure. Diaphragm ultrasound is a noninvasive method for measuring diaphragmatic function in mechanically ventilated children. In this study, significant diaphragm atrophy and a decreased DTF were observed within 24 hours of mechanical ventilation. The recovery of diaphragm thickness and the DTF may be a potential predictor of successful extubation from mechanical ventilation.

  3. The Therapeutic Outcomes of Mechanical Ventilation in Hematological Malignancy Patients with Respiratory Failure.

    PubMed

    Fujiwara, Yusuke; Yamaguchi, Hiroki; Kobayashi, Katsuya; Marumo, Atsushi; Omori, Ikuko; Yamanaka, Satoshi; Yui, Shunsuke; Fukunaga, Keiko; Ryotokuji, Takeshi; Hirakawa, Tsuneaki; Okabe, Masahiro; Wakita, Satoshi; Tamai, Hayato; Okamoto, Muneo; Nakayama, Kazutaka; Takeda, Shinhiro; Inokuchi, Koiti

    2016-01-01

    Objective In hematological malignancy patients, the complication of acute respiratory failure often reaches a degree of severity that necessitates mechanical ventilation. The objective of the present study was to investigate the therapeutic outcomes of mechanical ventilation in hematological malignancy patients with respiratory failure and to analyze the factors that are associated with successful treatment in order to identify the issues that should be addressed in the future. Methods The present study was a retrospective analysis of 71 hematological malignancy patients with non-cardiogenic acute respiratory failure who were treated with mechanical ventilation at Nippon Medical School Hospital between 2003 and 2014. Results Twenty-six patients (36.6%) were treated with mechanical ventilation in an intensive care unit (ICU). Non-invasive positive pressure ventilation (NPPV) was applied in 29 cases (40.8%). The rate of successful mechanical ventilation treatment with NPPV alone was 13.8%. The rate of endotracheal extubation was 17.7%. A univariate analysis revealed that the following factors were associated with the successful extubation of patients who received invasive mechanical ventilation: respiratory management in an ICU (p=0.012); remission of the hematological disease (p=0.011); female gender (p=0.048); low levels of accompanying non-respiratory organ failure (p=0.041); and the non-use of extracorporeal circulation (p=0.005). A subsequent multivariate analysis revealed that respiratory management in an ICU was the only variable associated with successful extubation (p=0.030). Conclusion The outcomes of hematological malignancy patients who receive mechanical ventilation treatment for respiratory failure are very poor. Respiratory management in an ICU environment may be useful in improving the therapeutic outcomes of such patients.

  4. [Long-term effects of home mechanical ventilation with positive pressure using a nasal mask].

    PubMed

    Escarrabill, J; Estopà, R; Robert, D; Casolivé, V; Manresa, F

    1991-10-05

    Home mechanical ventilation (HMV) is an efficient alternative in the treatment of patients with chronic respiratory failure secondary to restrictive mechanical disorders (neuromuscular disease, such as Duchenne's disease, thorax deformities due to kyphoscoliosis or tuberculosis sequelae). The case of a patient with severe kyphoscoliosis in the phase of chronic respiratory failure (PaO2 34 mmHg and PaCO2 61 mmHg, breathing ambient air) is presented in which, following the failure of negative pressure mechanical ventilation ("poncho"), positive pressure ventilation was tested with a silicon made-to-measure nasal mask as the access via. Adaptation to HMV was good with the patient using the ventilation nightly. Following 12 months of treatment the patient is able to carry out everyday activities and arterial gasometry breathing ambient air is PaO2 77 mmHg and PaCO2 43 mmHg.

  5. State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic shock.

    PubMed

    Wiesen, Jonathan; Ornstein, Moshe; Tonelli, Adriano R; Menon, Venu; Ashton, Rendell W

    2013-12-01

    The need to provide invasive mechanical ventilatory support to patients with myocardial infarction and acute left heart failure is common. Despite the large number of patients requiring mechanical ventilation in this setting, there are remarkably few data addressing the ideal mode of respiratory support in such patients. Although there is near universal acceptance regarding the use of non-invasive positive pressure ventilation in patients with acute pulmonary oedema, there is more concern with invasive positive pressure ventilation owing to its more significant haemodynamic impact. Positive end-expiratory pressure (PEEP) is almost universally applied in mechanically ventilated patients due to benefits in gas exchange, recruitment of alveolar units, counterbalance of hydrostatic forces leading to pulmonary oedema and maintenance of airway patency. The limited available clinical data suggest that a moderate level of PEEP is safe to use in severe left ventricular (LV) dysfunction and cardiogenic shock, and may provide haemodynamic benefits as well in LV failure which exhibits afterload-sensitive physiology.

  6. Total liquid ventilation provides superior respiratory support to conventional mechanical ventilation in a large animal model of severe respiratory failure.

    PubMed

    Pohlmann, Joshua R; Brant, David O; Daul, Morgan A; Reoma, Junewai L; Kim, Anne C; Osterholzer, Kathryn R; Johnson, Kent J; Bartlett, Robert H; Cook, Keith E; Hirschl, Ronald B

    2011-01-01

    Total liquid ventilation (TLV) has the potential to provide respiratory support superior to conventional mechanical ventilation (CMV) in the acute respiratory distress syndrome (ARDS). However, laboratory studies are limited to trials in small animals for no longer than 4 hours. The objective of this study was to compare TLV and CMV in a large animal model of ARDS for 24 hours. Ten sheep weighing 53 ± 4 (SD) kg were anesthetized and ventilated with 100% oxygen. Oleic acid was injected into the pulmonary circulation until PaO2:FiO2 ≤ 60 mm Hg, followed by transition to a protective CMV protocol (n = 5) or TLV (n = 5) for 24 hours. Pathophysiology was recorded, and the lungs were harvested for histological analysis. Animals treated with CMV became progressively hypoxic and hypercarbic despite maximum ventilatory support. Sheep treated with TLV maintained normal blood gases with statistically greater PO2 (p < 10(-9)) and lower PCO2 (p < 10(-3)) than the CMV group. Survival at 24 hours in the TLV and CMV groups were 100% and 40%, respectively (p < 0.05). Thus, TLV provided gas exchange superior to CMV in this laboratory model of severe ARDS.

  7. Total Liquid Ventilation Provides Superior Respiratory Support to Conventional Mechanical Ventilation in a Large Animal Model of Severe Respiratory Failure

    PubMed Central

    Pohlmann, Joshua R; Brant, David O; Daul, Morgan A; Reoma, Junewai L; Kim, Anne C; Osterholzer, Kathryn R; Johnson, Kent J; Bartlett, Robert H; Cook, Keith E; Hirschl, Ronald B

    2011-01-01

    Total liquid ventilation (TLV) has the potential to provide respiratory support superior to conventional mechanical ventilation (CMV) in the acute respiratory distress syndrome (ARDS). However, laboratory studies are limited to trials in small animals for no longer than 4 hours. The objective of this study was to compare TLV and CMV in a large animal model of ARDS for 24 hours. Ten sheep weighing 53 ± 4 (SD) kg were anesthetized and ventilated with 100% oxygen. Oleic acid was injected into the pulmonary circulation until PaO2:FiO2 ≥ 60 mmHg, followed by transition to a protective CMV protocol (n=5) or TLV (n=5) for 24 hours. Pathophysiology was recorded and the lungs were harvested for histological analysis. Animals treated with CMV became progressively hypoxic and hypercarbic despite maximum ventilatory support. Sheep treated with TLV maintained normal blood gases with statistically greater PO2 (p<10−9) and lower PCO2 (p < 10−3) than the CMV group. Survival at 24 hours in the TLV and CMV groups were 100% and 40% respectively (p< 0.05). Thus, TLV provided gas exchange superior to CMV in this laboratory model of severe ARDS. PMID:21084968

  8. Particle Size Concentration Distribution and Influences on Exhaled Breath Particles in Mechanically Ventilated Patients

    PubMed Central

    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. PMID:24475230

  9. Predictors of extubation failure and reintubation in newborn infants subjected to mechanical ventilation

    PubMed Central

    Costa, Ana Cristina de Oliveira; Schettino, Renata de Carvalho; Ferreira, Sandra Clecêncio

    2014-01-01

    Objective To identify risk factors for extubation failure and reintubation in newborn infants subjected to mechanical ventilation and to establish whether ventilation parameters and blood gas analysis behave as predictors of those outcomes. Methods Prospective study conducted at a neonatal intensive care unit from May to November 2011. A total of 176 infants of both genders subjected to mechanical ventilation were assessed after extubation. Extubation failure was defined as the need to resume mechanical ventilation within less than 72 hours. Reintubation was defined as the need to reintubate the infants any time after the first 72 hours. Results Based on the univariate analysis, the variables gestational age <28 weeks, birth weight <1,000g and low Apgar scores were associated with extubation failure and reintubation. Based on the multivariate analysis, the variables length of mechanical ventilation (days), potential of hydrogen (pH) and partial pressure of oxygen (pO2) remained associated with extubation failure, and the five-minute Apgar score and age at extubation were associated with reintubation. Conclusion Low five-minute Apgar scores, age at extubation, length of mechanical ventilation, acid-base disorders and hyperoxia exhibited associations with the investigated outcomes of extubation failure and reintubation. PMID:24770689

  10. [Noninvasive mechanical ventilation in Valencia, Spain: from theory to practice].

    PubMed

    Chiner, Eusebi; Llombart, Mónica; Martínez-García, Miguel Angel; Fernández-Fabrellas, Estrella; Navarro, Rafael; Cervera, Angela

    2009-03-01

    To obtain representative data on the frequency of use and availability of resources for noninvasive mechanical ventilation (NIV) in hospitals (acute respiratory failure) and at home (chronic respiratory failure). We sent a purpose-designed questionnaire to all the hospitals in the Autonomous Community of Valencia, Spain and followed up with a telephone interview. Seventy percent of the hospitals responded to the survey. NIV was used to treat patients with acute respiratory episodes in 100% of the intensive care units and in 88% of the respiratory medicine departments. The most common diseases were chronic obstructive pulmonary disease (COPD) (mean [SD] 60% [20%]), obesity hypoventilation syndrome (22% [12%]), neuromuscular diseases (6.5% [8%]), and kyphoscoliosis (6.5% [7%]). Other diseases accounted for 4% [11%] of cases. Emergency departments used NIV in 69% of patients, internal medicine departments in 37%, hospital-based home care units in 19%, and other departments in 12%. None of the hospitals that responded to the survey had an intermediate care unit and considerable differences were found in terms of NIV systems used. Home NIV was provided by 88% of hospitals. Patients using home NIV had COPD (31% [18%]), obesity hypoventilation syndrome (30% [18%]), neuromuscular diseases (16% [23%]), kyphoscoliosis (12% [10%]), and other diseases (11% [17%]). Patient numbers varied greatly from one hospital to the next. Home NIV was delivered using a nasal interface in 65% (32%) of cases, an oral-nasal interface in 33% (33%), a tracheostomy tube in 2% (3%), and a mouthpiece in 1% (32%). Only 31.3% of hospitals has a specialized home NIV unit. Home monitoring was performed mainly by service providers. We calculated that home NIV was used in 29 individuals per 100 000 population. Only 50% of the respiratory medicine departments surveyed had written hospitalization protocols; the corresponding percentages for other departments were 44% for home care units, 19% for emergency

  11. 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.

  12. Noninvasive Mechanical Ventilation in Acute Respiratory Failure Patients: A Respiratory Therapist Perspective.

    PubMed

    Hidalgo, V; Giugliano-Jaramillo, C; Pérez, R; Cerpa, F; Budini, H; Cáceres, D; Gutiérrez, T; Molina, J; Keymer, J; Romero-Dapueto, C

    2015-01-01

    Physiotherapist in Chile and Respiratory Therapist worldwide are the professionals who are experts in respiratory care, in mechanical ventilation (MV), pathophysiology and connection and disconnection criteria. They should be experts in every aspect of the acute respiratory failure and its management, they and are the ones who in medical units are able to resolve doubts about ventilation and the setting of the ventilator. Noninvasive mechanical ventilation should be the first-line of treatment in acute respiratory failure, and the standard of care in severe exacerbations of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and in immunosuppressed patients with high levels of evidence that support the work of physiotherapist. Exist other considerations where most of the time, physicians and other professionals in the critical units do not take into account when checking the patient ventilator synchrony, such as the appropriate patient selection, ventilator selection, mask selection, mode selection, and the selection of a trained team in NIMV. The physiotherapist needs to evaluate bedside; if patients are properly connected to the ventilator and in a synchronously manner. In Chile, since 2004, the physioterapist are included in the guidelines as a professional resource in the ICU organization, with the same skills and obligations as those described in the literature for respiratory therapists.

  13. Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis.

    PubMed

    Wang, C; Zhao, N; Wang, W; Guo, Libo; Guo, Lei; Chi, C; Wang, X; Pi, X; Cui, Y; Li, E

    2015-06-01

    Several intraoperative ventilation strategies are available for obese patients. However, the same ventilation interventions have exhibited different effects on PaO2 /FIO2 concerning obese patients in different trials, and the issue remains controversial. Therefore, we conducted a network meta-analysis to identify the optimal mechanical ventilation strategy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Embase, MEDLINE, CINAHL and Web of Science for studies published up to June 2014, and the PaO2 /FIO2 in obese patients given different mechanical ventilation strategies was assessed. We assessed the studies for eligibility and extracted data and then pooled the data and used a Bayesian fixed-effect model to combine direct comparisons with indirect evidence. Eligible studies evaluated different ventilation strategies for obese patients and reported the intraoperative PaO2 /FIO2 ratio, atelectasis and pulmonary compliance. Thirteen randomized controlled trials were included for network meta-analysis, including 476 patients who received 1 of 12 ventilation strategies. Volume-controlled ventilation with higher PEEP plus single recruitment manoeuvres (VCV + higher PEEP + single RM) was associated with the highest PaO2 /FiO2 ratio, improving intraoperative pulmonary compliance and reducing the incidence of intraoperative atelectasis. © 2015 World Obesity.

  14. Noninvasive Mechanical Ventilation in Acute Respiratory Failure Patients: A Respiratory Therapist Perspective

    PubMed Central

    Hidalgo, V; Giugliano-Jaramillo, C; Pérez, R; Cerpa, F; Budini, H; Cáceres, D; Gutiérrez, T; Molina, J; Keymer, J; Romero-Dapueto, C

    2015-01-01

    Physiotherapist in Chile and Respiratory Therapist worldwide are the professionals who are experts in respiratory care, in mechanical ventilation (MV), pathophysiology and connection and disconnection criteria. They should be experts in every aspect of the acute respiratory failure and its management, they and are the ones who in medical units are able to resolve doubts about ventilation and the setting of the ventilator. Noninvasive mechanical ventilation should be the first-line of treatment in acute respiratory failure, and the standard of care in severe exacerbations of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and in immunosuppressed patients with high levels of evidence that support the work of physiotherapist. Exist other considerations where most of the time, physicians and other professionals in the critical units do not take into account when checking the patient ventilator synchrony, such as the appropriate patient selection, ventilator selection, mask selection, mode selection, and the selection of a trained team in NIMV. The physiotherapist needs to evaluate bedside; if patients are properly connected to the ventilator and in a synchronously manner. In Chile, since 2004, the physioterapist are included in the guidelines as a professional resource in the ICU organization, with the same skills and obligations as those described in the literature for respiratory therapists. PMID:26312104

  15. Comparison of Chemical and Mechanical Prophylaxis of Venous Thromboembolism in Nonsurgical Mechanically Ventilated Patients

    PubMed Central

    Gaspard, Dany; Vito, Karen; Schorr, Christa; Hunter, Krystal; Gerber, David

    2015-01-01

    Background. Thromboembolic events are major causes of morbidity, and prevention is important. We aimed to compare chemical prophylaxis (CP) and mechanical prophylaxis (MP) as methods of prevention in nonsurgical patients on mechanical ventilation. Methods. We performed a retrospective study of adult patients admitted to the Cooper University Hospital ICU between 2002 and 2010. Patients on one modality of prophylaxis throughout their stay were included. The CP group comprised 329 patients and the MP group 419 patients. The primary outcome was incidence of thromboembolic events. Results. Acuity measured by APACHE II score was comparable between the two groups (p = 0.215). Univariate analysis showed 1 DVT/no PEs in the CP group and 12 DVTs/1 PE in the MP group (p = 0.005). Overall mortality was 34.3% and 50.6%, respectively. ICU LOS was similar. Hospital LOS was shorter in the MP group. Multivariate analysis showed a significantly higher incidence of events in the MP prophylaxis group (odds ratio 9.9). After excluding patients admitted for bleeding in both groups, repeat analysis showed again increased events in the MP group (odds ratio 2.9) but this result did not reach statistical significance. Conclusion. Chemical methods for DVT/PE prophylaxis seem superior to mechanical prophylaxis in nonsurgical patients on mechanical ventilation and should be used when possible. PMID:26682067

  16. Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study.

    PubMed

    McKenna, Brian; McEvedy, Samantha; Maguire, Tessa; Ryan, Jo; Furness, Trentham

    2017-10-01

    Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings. © 2017 Australian College of Mental Health Nurses Inc.

  17. Can the Flutter Valve improve respiratory mechanics and sputum production in mechanically ventilated patients? A randomized crossover trial.

    PubMed

    Chicayban, Luciano M; Zin, Walter A; Guimarães, Fernando S

    2011-01-01

    The Flutter Valve (Varioraw SARL, Scandipharm Inc, Birmingham, AL) has proven efficacy in hypersecretive spontaneously ventilated patients. This study was designed to evaluate whether an airway clearance protocol using the Flutter Valve can af