Limited critical care subspecialty training and experience is available in many low- and middle-income countries, creating barriers to the delivery of evidence-based critical care. We hypothesized ...that a structured tele-education critical care program using case-based learning and ICU management principles is an efficient method for knowledge translation and quality improvement in this setting.
Weekly 45-min case-based tele-education rounds were conducted in the recently established medical intensive care unit (MICU) in Banja Luka, Bosnia and Herzegovina. The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) was used as a platform for structured evaluation of critically ill cases. Two practicing US intensivists fluent in the local language served as preceptors using a secure two-way video communication platform. Intensive care unit structure, processes, and outcomes were evaluated before and after the introduction of the tele-education intervention.
Patient demographics and acuity were similar before (2015) and 2 years after (2016 and 2017) the intervention. Sixteen providers (10 physicians, 4 nurses, and 2 physical therapists) evaluated changes in the ICU structure and processes after the intervention. Structural changes prompted by the intervention included standardized admission and rounding practices, incorporation of a pharmacist and physical therapist into the interprofessional ICU team, development of ICU antibiogram and hand hygiene programs, and ready access to point of care ultrasound. Process changes included daily sedation interruption, protocolized mechanical ventilation management and liberation, documentation of daily fluid balance with restrictive fluid and transfusion strategies, daily device assessment, and increased family presence and participation in care decisions. Less effective (dopamine, thiopental, aminophylline) or expensive (low molecular weight heparin, proton pump inhibitor) medications were replaced with more effective (norepinephrine, propofol) or cheaper (unfractionated heparin, H2 blocker) alternatives. The intervention was associated with reduction in ICU (43% vs 27%) and hospital (51% vs 44%) mortality, length of stay (8.3 vs 3.6 days), cost savings ($400,000 over 2 years), and a high level of staff satisfaction and engagement with the tele-education program.
Weekly, structured case-based tele-education offers an attractive option for knowledge translation and quality improvement in the emerging ICUs in low- and middle-income countries.
Cardiac arrest survivors may have disabilities due to hypoxic brain injury. Patients with obstructive sleep apnea are exposed to intermittent hypoxemia that may lead to ischemic preconditioning. We ...have hypothesized that patients with obstructive sleep apnea have better neurological outcomes following a cardiac arrest due to preconditioning of the brain.
We retrospectively analyzed all the survivors of in-hospital cardiac arrest from January 2006 to September 2016. Patients with confirmed or suspected obstructive sleep apnea were selected for further analysis and those without were used as comparison. Primary outcome was neurological functionality on hospital discharge by the Cerebral Performance Category.
A total of 739 patients had cardiac arrest within the study period. The immediate mortality rate was 59% (N=43) in patients with obstructive sleep apnea and 94% (N=623) in those without (p<0.001). Approximately 10% (N=73) were discharged alive and these were selected for further analysis. Patients without obstructive sleep apnea had more frequently “Poor” outcomes compared to those with obstructive sleep apnea (OR 2.91; 95% CI, 1.11–7.66; p=0.03). After adjusting in a multivariate analysis, obstructive sleep apnea was “protective” of “Poor” neurological outcomes: adjusted OR 0.21; 95% CI, 0.06–0.64; p=0.01.
Patients with obstructive sleep apnea had better unadjusted survival rates, and favorable adjusted neurological outcomes at discharge compared to those without obstructive sleep apnea. These results suggest that obstructive sleep apnea patients may tolerate better acute brain ischemia due to preconditioning.
OBJECTIVES:Effective pharmacologic treatments directly targeting lung injury in patients with the acute respiratory distress syndrome are lacking. Early treatment with inhaled corticosteroids and ...beta agonists may reduce progression to acute respiratory distress syndrome by reducing lung inflammation and enhancing alveolar fluid clearance.
DESIGN:Double-blind, randomized clinical trial (ClinicalTrials.govNCT01783821). The primary outcome was longitudinal change in oxygen saturation divided by the FIO2 (S/F) through day 5. We also analyzed categorical change in S/F by greater than 20%. Other outcomes included need for mechanical ventilation and development of acute respiratory distress syndrome.
SETTING:Five academic centers in the United States.
PATIENTS:Adult patients admitted through the emergency department at risk for acute respiratory distress syndrome.
INTERVENTIONS:Aerosolized budesonide/formoterol versus placebo bid for up to 5 days.
MEASUREMENTS AND MAIN RESULTS:Sixty-one patients were enrolled from September 3, 2013, to June 9, 2015. Median time from presentation to first study drug was less than 9 hours. More patients in the control group had shock at enrollment (14 vs 3 patients). The longitudinal increase in S/F was greater in the treatment group (p = 0.02) and independent of shock (p = 0.04). Categorical change in S/F improved (p = 0.01) but not after adjustment for shock (p = 0.15). More patients in the placebo group developed acute respiratory distress syndrome (7 vs 0) and required mechanical ventilation (53% vs 21%).
CONCLUSIONS:Early treatment with inhaled budesonide/formoterol in patients at risk for acute respiratory distress syndrome is feasible and improved oxygenation as assessed by S/F. These results support further study to test the efficacy of inhaled corticosteroids and beta agonists for prevention of acute respiratory distress syndrome.
The development of acute respiratory distress syndrome (ARDS) carries significant risk of morbidity and mortality. To date, pharmacological therapy has been largely ineffective for patients with ...ARDS. We present our personal review aimed at outlining current and future directions for the pharmacological prevention of ARDS.
Several available risk-stratification or prediction score strategies for identification of patients at risk of ARDS have been reported. Although not ready for clinical everyday use, they are and will be instrumental in the ongoing and future trials of pharmacoprevention of ARDS.
Several systemic medications established the potential role in ARDS prevention based on the preclinical studies and observational data. Due to potential for systemic adverse effects to neutralize any pharmacological benefits of systemic therapy, inhaled medications appear particularly attractive candidates for ARDS prevention. This is because of their direct delivery to the site of proposed action (lungs), while the pulmonary epithelial surface is still functional.
We postulate that overall morbidity and mortality rates from ARDS in the future will be contingent upon decreasing the overall incidence of ARDS through effective identification of those at risk and early application of proven supportive care and pharmacological interventions.
A 71-year-old man with advanced pancreatic carcinoma who was receiving chemoradiation therapy presented with diffuse abdominal pain and vomiting. An abdominal film and CT scans showed intestinal ...pneumatosis along the stomach and duodenum, portal venous gas, and bowel thickening.
A 71-year-old man with advanced pancreatic carcinoma who was receiving neoadjuvant chemoradiation therapy presented with a 12-hour history of diffuse abdominal pain and vomiting with associated abdominal tenderness and rigidity. A plain abdominal film (Panel A) and computed tomographic scans (Panels B and C) revealed intestinal pneumatosis along the contour of the stomach and duodenum (Panel A, pylorus and duodenum, two arrows at lower left; lesser curvature of stomach, single arrow at top; greater curvature of stomach, three arrows at lower right), portal venous gas (Panel C, arrow), and adjacent bowel thickening. His poor oncologic prognosis, the extent of the . . .
OBJECTIVE:Although ventilation with small tidal volumes is recommended in patients with established acute lung injury, most others receive highly variable tidal volume aimed in part at normalizing ...arterial blood gas values. We tested the hypothesis that acute lung injury, which develops after the initiation of mechanical ventilation, is associated with known risk factors for ventilator-induced lung injury such as ventilation with large tidal volume.
DESIGN:Retrospective cohort study.
SETTING:Four intensive care units in a tertiary referral center.
PATIENTS:Patients who received invasive mechanical ventilation for ≥48 hrs between January and December 2001.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:The main outcome of interest, acute lung injury, was assessed by independent review of daily digital chest radiographs and arterial blood gases. Ventilator settings, hemodynamics, and acute lung injury risk factors were extracted from the Acute Physiology and Chronic Health Evaluation III database and the patientsʼ medical records. Of 332 patients who did not have acute lung injury from the outset, 80 patients (24%) developed acute lung injury within the first 5 days of mechanical ventilation. When expressed per predicted body weight, women were ventilated with larger tidal volume than men (mean 11.4 vs. 10.4 mL/kg predicted body weight, p < .001) and tended to develop acute lung injury more often (29% vs. 20%, p = .068). In a multivariate analysis, the main risk factors associated with the development of acute lung injury were the use of large tidal volume (odds ratio 1.3 for each mL above 6 mL/kg predicted body weight, p < .001), transfusion of blood products (odds ratio, 3.0; p < 0.001), acidemia (pH < 7.35; odds ratio, 2.0; p = .032) and a history of restrictive lung disease (odds ratio, 3.6; p = .044).
CONCLUSIONS:The association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome. Height and gender should be considered when setting up the ventilator. Strong consideration should be given to limiting large tidal volume, not only in patients with established acute lung injury but also in patients at risk for acute lung injury.
Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, ...it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets.
BACKGROUND Pulmonary aspiration is an important recognized cause of ARDS. Better characterization of patients who aspirate may allow identification of potential risks for aspiration that could be ...used in future studies to mitigate the occurrence of aspiration and its devastating complications. METHODS We conducted a secondary analysis of the Lung Injury Prediction Score cohort to better characterize patients with aspiration, including their potential risk factors and related outcomes. RESULTS Of the 5,584 subjects at risk for ARDS and who required hospitalization, 212 (3.8%) presented with aspiration. Subjects who aspirated were likely to be male (66% vs 56%, P < .007), slightly older (59 years vs 57 years), white (73% vs 61%, P = .0004), admitted from a nursing home (15% vs 5.9%, P < .0001), have a history of alcohol abuse (21% vs 8%, P < .0001), and have lower Glasgow Coma Scale (median, 13 vs 15; P < .0001). Aspiration subjects were sicker (higher APACHE Acute Physiology and Chronic Health Evaluation II score), required more mechanical ventilation (54% vs 32%, P < .0001), developed more moderate to severe ARDS (12% vs 3.8%, P < .0001), and were twofold more likely to die in-hospital, even after adjustment for severity of illness (OR = 2.1; 95% CI, 1.2-3.6). Neither obesity nor gastroesophageal reflux was associated with aspiration. CONCLUSIONS Aspiration was more common in men with alcohol abuse history and a lower Glasgow Coma Scale who were admitted from a nursing home. It is independently associated with a significant increase in the risk for ARDS as well as morbidity and mortality. Findings from this study may facilitate the design of future clinical studies of aspiration-induced lung injury.
To address clinical concern regarding the use of inhaled corticosteroids (ICSs) and the risk for pneumonia, particularly among patients with chronic obstructive pulmonary disease (COPD) and asthma.
A ...multicentered prospective cohort of patients admitted to the hospital from March 1, 2009, through August 31, 2009, with pneumonia or another risk factor for acute respiratory distress syndrome was analyzed to determine the risk for pneumonia requiring hospitalization among patients taking ICSs. The adjusted risk (odds ratio OR) for developing pneumonia because of ICSs was determined in a multiple logistic regression model.
Of the 5584 patients in the cohort, 495 (9%) were taking ICSs and 1234 (22%) had pneumonia requiring hospitalization. In univariate analyses, pneumonia occurred in 222 (45%) of the patients on ICSs vs 1012 (20%) in those who were not (OR, 3.28; 95% CI, 2.71-3.96; P<.001). After adjusting in the logistic regression model, prehospital ICS use was not significantly associated with pneumonia in the whole cohort (OR, 1.20; 95% CI, 0.93-1.53; P=.162), among the subset of 589 patients with COPD (OR, 1.40; 95% CI, 0.95-2.09; P=.093), among the 440 patients with asthma (OR, 1.07; 95% CI, 0.61-1.87; P=.81), nor among the remaining 4629 patients without COPD or asthma (OR, 1.32; 95% CI, 0.88-1.97; P=.179).
When adjusted for multiple confounding variables, ICS use was not substantially associated with an increased risk for pneumonia requiring admission in our cohort.
Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often goes undiagnosed. OSA is characterized mainly by anatomical obstruction or partial collapse of upper ...airways during sleep. The obstruction is multifactorial, and a lesser-known fact is that damage to the pharyngeal plexus during head and neck procedures or placement of hardware in the cervical area can lead to narrowing or collapse of the upper airway. We present such a case of a 59-year-old female who developed new-onset OSA after undergoing anterior cervical discectomy and fusion (ACDF). The severity of OSA worsened with the progression of her rheumatoid arthritis (RA) in the cervical region. This case report aims to raise awareness of such an association among clinicians to enable them to screen appropriate patients for sleep-disordered breathing and treat them accordingly.
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