OBJECTIVE:Right-to-left shunting across a patent foramen ovale may occur in acute respiratory distress syndrome as a result of pulmonary hypertension and positive-pressure mechanical ventilation. The ...shunt may worsen the hypoxemia. The objective of our study was to determine the prevalence, clinical implications, and prognosis of patent foramen ovale shunting during acute respiratory distress syndrome.
DESIGN:Prospective study.
SETTING:Medical intensive care unit of a university hospital in Créteil, France.
PATIENTS:Two hundred three consecutive patients with acute respiratory distress syndrome.
INTERVENTIONS:Patent foramen ovale shunting was detected by using transesophageal echocardiography with modified gelatin contrast. Moderate-to-large shunting was defined as right-to-left passage of at least 10 bubbles through a valve-like structure within three cardiac cycles after complete opacification of the right atrium. In 85 patients without and 31 with shunting, the influence of the positive end-expiratory pressure level on shunting was studied.
MEASUREMENTS AND RESULTS:The prevalence of moderate-to-large patent foramen ovale shunting was 19.2% (39 patients). Compared to those in the group without shunting, the patients in group with shunting had larger right ventricle dimensions, higher pulmonary artery systolic pressure, and a higher prevalence of cor pulmonale. Compared to patients without shunting, patients with shunting had a poorer Pao2/Fio2 ratio response to positive end-expiratory pressure, more often required prone positioning and nitric oxide as adjunctive interventions, and had fewer ventilator-free and intensive care unit-free days within the first 28 days.
CONCLUSIONS:Moderate-to-large patent foramen ovale shunting occurred in 19.2% of patients with acute respiratory distress syndrome, in keeping with findings from autopsy studies. Patent foramen ovale was associated with a poor oxygenation response to positive end-expiratory pressure, greater use of adjunctive interventions, and a longer intensive care unit stay.
OBJECTIVE:To compare the physiologic effects of noninvasive pressure-support ventilation (NPSV) delivered by a facemask, a helmet with the same settings, and a helmet with specific settings. ...Inspiratory muscle effort, gas exchange, patient-ventilator synchrony, and comfort were evaluated.
DESIGN:Prospective crossover study.
SETTING:A 13-bed medical intensive care unit in a university hospital.
PATIENTS:Eleven patients at risk for respiratory distress requiring early NPSV after extubation.
INTERVENTION:One hour after extubation, three 20-minute NPSV periods were delivered in a random order by facemask, helmet, and helmet with 50% increases in both pressure support and positive end-expiratory pressure and with the highest pressurization rate (95% max).
MEASUREMENTS AND MAIN RESULTS:Flow and airway, esophageal, and gastric pressure signals were measured under the three NPSV conditions and during spontaneous breathing. Compared with the facemask, the helmet with the same settings resulted in a greater inspiratory muscle effort, but this difference was abolished by the specific settings (pressure-time product in cm H2O·s·min, 63.8 27.3–85.9, 81.8 36.0–111.5, and 58.0 25.4–79.5, respectively, p < 0.05, compared with 209.3 29.8–239.6 during spontaneous breathing). Compared with the facemask, the helmet with the same settings worsened patient-ventilator synchrony, as indicated by longer triggering-on and cycling-off delays (0.14 0.11–0.20 seconds vs. 0.32 0.26–0.43 seconds, p < 0.05; and 0.20 0.08–0.24 seconds vs. 0.27 0.25–0.35 seconds, p < 0.01, respectively). The specific settings significantly improved the triggering-on delay compared with the helmet without specific settings (p < 0.01). Tolerance was the same with the three methods.
CONCLUSIONS:Our results suggest that increasing both the pressure-support level and positive end-expiratory pressure and using the highest pressurization rate may be advisable when providing NPSV via a helmet.
OBJECTIVE:To determine whether sleep quality helps to predict noninvasive ventilation outcome in patients with acute hypercapnic respiratory failure. Despite an initial clinical improvement, nearly ...one fourth of patients may fail noninvasive ventilation after several days. Because late intubation is associated with a poor prognosis, it may be useful to identify factors that may predict or explain late noninvasive ventilation failure.
PATIENTS:We prospectively studied 27 hypercapnic patients in a medical intensive care unit who required noninvasive ventilation for >48 hrs.
INTERVENTIONS:A 17-hr sleep polysomnography (3 pm–8 am) was recorded 2 days to 4 days after noninvasive ventilation initiation. Late noninvasive ventilation failure was defined as death, endotracheal intubation, or persistent need for noninvasive ventilation on day 6.
MEASUREMENTS AND MAIN RESULTS:An abnormal electroencephalographic pattern that eluded analysis by standard sleep-scoring criteria was noted in seven (50%) of the 14 patients with late noninvasive ventilation failure compared with one (8%) of the 13 patients successfully treated with noninvasive ventilation (p = .03). No clinical or laboratory variables explained the electroencephalographic differences. Patients failing noninvasive ventilation had poorer sleep quality with greater circadian sleep-cycle disruption and less nocturnal rapid eye movement sleep (6 mins range, 0–12 vs. 26 mins range, 6–49, p = .03), compared with patients successfully treated with noninvasive ventilation. Noninvasive ventilation failure was associated with delirium during the intensive care unit stay (64% vs. 0%).
CONCLUSIONS:Late noninvasive ventilation failure in elderly patients with acute hypercapnic respiratory failure was associated with early sleep disturbances including an abnormal electroencephalographic pattern, disruption of the circadian sleep cycle, and decreased rapid eye movement sleep.
Objective
Patients with severe acute respiratory distress syndrome (ARDS) often require prolonged sessions of prone position (PP) because of refractory hypoxemia. Because of frequent hemodynamic ...impairment, use of transesophageal echocardiography (TEE) is also advocated during ARDS, but its implementation during PP has not been described yet. Our objective is to report the feasibility, tolerance, and therapeutic implications of TEE during PP for severe ARDS, and to compare it with TEE performed supine.
Methods
Prospective study in the medical intensive care unit of a university hospital.
Results
A total of 34 patients with ARDS underwent TEE in PP. Probe insertion was successful in all but one patient, and vital signs did not change during insertion. All standard views and measures could be obtained, except for patent foramen ovale in one patient, and cardiac output assessment in four patients. TEE examinations were all conclusive and led to therapeutic change proposal in 23 patients (70%). TEE was performed in both supine and PP in 16 patients within a median delay of 3 days. There was no difference between the two examinations in terms of feasibility, tolerance, therapeutic implication, and image quality. In ten healthy individuals, we also explored the minimal cross-sectional area of the oropharyngeal duct with the acoustic reflection technique; it was found identical in supine and PP.
Conclusions
TEE can be performed safely and efficiently in severe ARDS patients in PP. PP is not associated with a significant change in the oropharyngeal tract cross-section in healthy individuals.
BACKGROUND Delirium is frequent in patients in the ICU, but its association with the outcome of weaning from mechanical ventilation has not been assessed. Circadian rhythm alteration may favor ...delirium. In the current study, we assessed the impact of delirium during weaning and associated alterations in the circadian rhythm of melatonin excretion. METHODS This was a substudy of 70 participants of the B-type Natriuretic Peptide for the Fluid Management of Weaning trial, comparing two fluid management strategies during weaning. Patients with or without delirium (as assessed using the Confusion Assessment Method for the ICU) were compared in terms of baseline characteristics and outcomes and the circadian rhythm of melatonin excretion using the 24-h excretion of its urinary metabolite 6-sulfatoxymelatonin (aMT6s). RESULTS Among the 70 patients included, 43 (61.4%) experienced delirium at the initiation of weaning. Delirium at the initiation of weaning was associated with more alcohol consumption, a greater severity of illness, and medication use before weaning (including neuromuscular blockade, antibiotics, sedatives, and narcotics). Delirium at the initiation of weaning was associated with more respiratory and neurologic complications and a reduced probability of successful extubation (Cox multivariate model hazard ratio of successful extubation = 0.54; 95% CI, 0.30-0.95; P = .03). Delirium was also associated with a significant reduction in peak, mean, amplitude, and total values of aMT6s urinary excretion during the first 24 h of weaning (general linear model F statistic = 5.81, P = .019). CONCLUSIONS Delirium is frequent at the initiation of ventilator weaning. It is associated with a prolongation of weaning and an alteration in the circadian rhythm of melatonin excretion. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov
Abstract Background Patients in intensive care units (ICUs) experience severe sleep alterations and conventional sleep scoring rules are difficult to use in these patients. In a previous study, we ...showed that abnormal sleep EEG and wake EEG patterns could predict the outcome of noninvasive ventilation in a group of patients treated for acute respiratory failure. Our aims were to assess the prevalence of these abnormal sleep/wake EEG patterns in a larger group and search for objective parameters to help their identification. Methods We reviewed sleep studies previously performed with full polysomnography during 17-h in conscious nonsedated ICU patients receiving invasive ventilation during weaning or noninvasive ventilation for acute respiratory failure. Results We included 57 patients. Sleep scoring using conventional rules was not feasible in 16 (28%) patients due to the absence of stage-2 markers. Wake EEG in these 16 patients, although recognizable, showed abnormal features, including decreased reactivity to eye opening and slower peak EEG frequency compared to patients with normal sleep–wake EEGs. Conclusion In almost one third of awake mechanically ventilated ICU patients, sleep cannot be classified with standard criteria. Two new states, atypical sleep and pathologic wakefulness, need to be added. We suggest rules for scoring these states. The origin and links with outcomes of these abnormal EEG patterns deserve investigation.
Aim
To compare the effectiveness and safety of fentanyl with placebo as pre‐emptive treatment for pain associated with turning in patients in intensive care units.
Background
Turning is frequently a ...painful procedure in this setting. Pre‐emptive administration of supplementary analgesia may help decrease this pain. However, medical literature on pre‐emptive analgesia in these patients is scarce.
Design
A randomized, double‐blind, controlled clinical trial.
Methods
This study will assess the benefits and risks of pre‐emptive analgesia with fentanyl compared with placebo on turning‐associated pain. Eighty patients will be recruited from among those older than 18 years and needing mechanical ventilation for at least 24 hours. Pain intensity will be assessed using the Behavioral Pain Scale. Primary outcome will be pain intensity between the baseline and 30 minutes after turning, measured by the area under the curve of the pain scale scores. Secondary outcomes will be the usefulness of physiological parameters and the Bispectral Index to measure pain and the safety of pre‐emptive fentanyl in turning. The study protocol was approved in February 2011.
Discussion
If pre‐emptive fentanyl is more effective than placebo and reasonably safe, the results of the current study may change nursing attitude in managing turning in critically ill patients. As a consequence, pain may be decreased during this nursing procedure.
Background
Cardiac dysfunction is a common cause of weaning failure. Weaning shares some similarities with a cardiac stress test and may challenge active phases of the cardiac cycle-like ventricular ...contractility and relaxation. This study aimed at assessing systolic and diastolic function during the weaning process and scrutinizing their dynamics during weaning trials.
Methods
Echocardiography was performed during baseline ventilator settings to assess cardiac function at the initiation of the weaning process and at the start and the end of consecutive weaning trials (performed at day-1, day-2, and before extubation if applicable) to explore the evolution of left ventricle contractility and relaxation in a subset of patients.
Results
Among 67 patients included, weaning was prolonged (≥ 7 days) in 18 (27%) patients and short (< 7 days) in 49 (73%). Prevalence of systolic dysfunction and isolated diastolic dysfunction before the initiation of weaning process were 37 and 17%, respectively. Isolated diastolic dysfunction was more frequent in patients with prolonged weaning as compared to their counterparts. Thirty-one patients were explored by echocardiography during consecutive weaning trials. An increase in filling pressures with an alteration of ventricular relaxation (as assessed by a decrease in tissue Doppler early mitral diastolic wave velocity) was found during failed weaning trials.
Conclusions
Isolated diastolic dysfunction was associated with a prolongation of weaning. Increased filling pressures with left ventricle relaxation impairment may be a key mechanism of weaning trial failure.
Background
The SARS-CoV-2 omicron variant produces more symptoms in the upper respiratory tract than in the lower respiratory tract. This form of “common cold” can cause inflammation of the ...oropharynx and the Eustachian tube, leading to the multiplication of bacteria such as Streptococcus pneumoniae in the oropharynx. Eustachian tube dysfunction facilitates migration of these bacteria to the middle ear, causing inflammation and infection (otitis media), which in turn could lead to further complications such as acute mastoiditis and meningitis.
Case presentation
In January 2022, during the rapid spread of the omicron variant of the SARS-CoV-2 virus, two patients presented to the emergency room at our hospital complaining of headache and a low level of consciousness. A few days prior to admission, the patients had been diagnosed with COVID-19 based on clinical manifestations of a cold virus, without respiratory failure. Cranial computed tomography revealed signs of bilateral invasion of the middle ear in both cases. Lumbar puncture was compatible with acute bacterial meningitis, and S. pneumoniae was isolated in cerebrospinal fluid in both patients. RT-PCR tests for SARS-CoV-2 were repeated, confirming the presence of the omicron variant in one of the patients. We were unable to confirm the variant in the second patient due to the low viral load in the nasopharyngeal sample obtained at admission. However, the time of diagnosis (i.e., during the peak spread of the omicron variant), strongly suggest the presence of the omicron variant. Both patients were admitted to the intensive care unit and both showed rapid clinical improvement after initiation of antibiotic treatment.
Conclusions
The omicron variant of the SARS-CoV-2 virus can promote the development of otitis media and secondary acute bacterial meningitis. S. pneumoniae is one of the main bacteria involved in this process.
BACKGROUND Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated ...pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation. METHODS We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model). RESULTS Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group ( P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios 25th-75th percentiles, 0.44 0.22-0.87, P = .02 and 0.50 0.25-0.96, P = .03, respectively). CONCLUSIONS Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov
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