To conduct a blinded evaluation of the predictors of weaning from mechanical ventilation.
A prospective clinical study.
A 23-bed general intensive care unit.
Ninety-three non-selected patients, ...ventilated for more than 48 h.
The study had two steps: at first, patients' data were used to select the cut-off value for weaning predictors (the minimal false classification). The cut-off value for each index was prospectively assessed in a group of 52 patients. The predictive performance of these indexes was evaluated by calculating the area under the receiver operating characteristic curve. In the prospective-validation set we used Bayes' theorem to assess the probability of each test in predicting weaning. The physicians making decisions about the weaning process were always unaware of the predictive values. Weaning was considered successful if spontaneous breathing was sustained for more than 48 h after extubation.
During the first 2 min after discontinuation of mechanical ventilation the following tests were performed: vital capacity, tidal volume, airway occlusion pressure (P(0.1)), minute ventilation, respiratory rate, maximal inspiratory pressure (MIP), respiratory frequency to tidal volume (f/V(T)), P(0.1)/MIP and P(0.1) x f/V(T). The areas under the curve showed that the tests had not the ability to distinguish between successful and unsuccessful weaning.
Our results show that all the evaluated indexes are poor predictors of weaning outcome in a general intensive care unit population.
Secretory phospholipase A2 (sPLA2) plays a pivotal role in acute respiratory distress syndrome (ARDS). This enzyme seems an interesting target to reduce surfactant catabolism and lung tissue ...inflammation. Varespladib is a specifically designed indolic sPLA2 inhibitor, which has shown promising results in animals and adults. No specific data in pediatric ARDS patients are yet available.
We studied varespladib in broncho-alveolar lavage (BAL) fluids obtained ex vivo from pediatric ARDS patients. Clinical data and worst gas exchange values during the ARDS course were recorded. Samples were treated with saline or 10-40-100 µM varespladib and incubated at 37°C. Total sPLA2 activity was measured by non-radioactive method. BAL samples were subjected to western blotting to identify the main sPLA isotypes with different sensitivity to varespladib. Results was corrected for lavage dilution using the serum-to-BAL urea ratio and for varespladib absorbance.
Varespladib reduces sPLA2 activity (p<0.0001) at 10,40 and 100 µM; both sPLA2 activity reduction and its ratio to total proteins significantly raise with increasing varespladib concentrations (p<0.001). IC(50) was 80 µM. Western blotting revealed the presence of sPLA2-IIA and -IB isotypes in BAL samples. Significant correlations exist between the sPLA2 activity reduction/proteins ratio and PaO(2) (rho = 0.63;p<0.001), PaO(2)/FiO(2) (rho = 0.7; p<0.001), oxygenation (rho = -0.6; p<0.001) and ventilation (rho = -0.4;p = 0.038) indexes.
Varespladib significantly inhibits sPLA2 in BAL of infants affected by post-neonatal ARDS. Inhibition seems to be inversely related to the severity of gas exchange impairment.
Acute myocardial edema (AME) is increased water content in the myocardium and represents the first and transient pathophysiological response to an acute myocardial injury. In-vivo and non-invasive ...evaluation is feasible with cardiac magnetic resonance (CMR), which is a powerful imaging technique capable of tissue characterization. In the clinical setting, early demonstration of AME has a recognized diagnostic value for acute coronary syndromes and acute myocarditis, although its prognostic value is not well established. This article provides a comprehensive narrative review on the clinical meaning of AME in heart diseases. In particular, the available evidence of a possible favourable prognostic value in several clinical scenarios is addressed.
We have reported previously on the use of noninvasive positive-pressure ventilation (NPPV) to assist spontaneous breathing in high-risk hypoxemic patients (ie, Pao2/fraction of inspired oxygen Fio2 ...ratio, ≤ 100) who are undergoing diagnostic fiberoptic bronchoscopy (FOB). The efficacy of this intervention in patients with less severe forms of hypoxemia (ie, Pao2/Fio2 ratio, < 200) is unknown.
Twenty-six patients with Pao2/Fio2 ratios ≤ 200 who required bronchoscopic BAL for suspected nosocomial pneumonia were entered into the study. Thirteen patients were randomized during FOB to receive NPPV, and 13 patients were randomized to receive conventional oxygen supplementation by Venturi mask. The primary end points were changes in the Pao2/Fio2 ratio during FOB and within 60 min of terminating the procedure.
At study entry, the two groups were similar in terms of age, simplified acute physiologic score II values, and cardiorespiratory parameters. During FOB, the mean (± SD) Pao2/Fio2 ratio increased by 82% in the NPPV group (261 ± 100 vs 139 ± 38; p < 0.001) and decreased by 10% in the conventional oxygen supplementation group (155 ± 24 to 139 ± 38; p = 0.23). Sixty minutes after undergoing FOB, the NPPV group had a higher mean Pao2/Fio2 ratio (176 ± 62 vs 140 ± 38; p = 0.09), a lower mean heart rate (91 ± 18 vs 108 ± 15 beats/min; p = 0.02), and no reduction in mean arterial pressure in comparison to a 15% decrease from the baseline in the control group. One patient in the NPPV group and two patients in the control group required nonemergent intubation. Major bacterial isolates included Staphylococcus aureus (7 of 30 isolates; 23%) and Pseudomonas aeruginosa (12 of 30 isolates; 40%).
In patients with severe hypoxemia, NPPV is superior to conventional oxygen supplementation in preventing gas-exchange deterioration during FOB with better hemodynamic tolerance.
Recently, a diagnostic strategy using a clinical decision rule, D-dimer testing and spiral computed tomography (CT) was found to be effective in the evaluation of patients with clinically suspected ...pulmonary embolism (PE). However, the rate of venous thromboembolic complications in the three-month follow-up of patients with negative CT was still substantial and included fatal events. It was the objective to evaluate the safety of withholding anticoagulants after a normal 64-detector row CT (64-DCT) scan from a cohort of patients with suspected PE. A total of 545 consecutive patients with clinically suspected first episode of PE and either likely pre-test probability of PE (using the simplified Wells score) or unlikely pre-test probability in combination with a positive D-dimer underwent a 64-DCT. 64-DCT scanning was inconclusive in nine patients (1.6%), confirmed the presence of PE in 169 (31%), and ruled out the diagnosis in the remaining 367. During the three-month follow-up of the 367 patients one developed symptomatic distal deep-vein thrombosis (0.27%; 95%CI, 0.0 to 1.51%) and none developed PE (0 %; 95%CI, 0 to 1.0%). We conclude that 64-DCT scanning has the potential to safely exclude the presence of PE virtually in all patients presenting with clinical suspicion of this clinical disorder.
Mechanical ventilation for children Conti, Giorgio; Piastra, Marco
Current opinion in critical care,
02/2016, Letnik:
22, Številka:
1
Journal Article
The aim of this review is to analyze innovative data pertaining to the clinical use of mechanical ventilation for children.
The optimal definition and treatment of pediatric acute respiratory ...distress syndrome, the application of innovative ventilation modes in children to optimize child/ventilator interaction, and pediatric noninvasive ventilation, including specific interfaces, have been recently evaluated in the literature.
Despite the improvement observed in the last decades in the treatment of pediatric acute respiratory failure and the diffusion of innovative modes of mechanical ventilation, there are no clear and consistent guidelines for the use of mechanical ventilation for children. In several areas data are still lacking, and in many others they are extrapolated from studies performed in adults; the direct evaluation of results obtained from studies specific to the pediatric population is therefore crucial.
The aim of this study was to validate a composed coronavirus disease 2019 (COVID-19) chest radiography score (CARE) based on the extension of ground-glass opacity (GG) and consolidations (Co), ...separately assessed, and to investigate its prognostic performance.
COVID-19-positive patients referring to our tertiary centre during the first month of the outbreak in our area and with a known outcome were retrospectively evaluated. Each lung was subdivided into three areas and a three-grade score assessing the extension of GG and Co was used. The CARE was derived from the sum of the subscores. A mixed-model ANOVA with
Bonferroni correction was used to evaluate whether differences related to the referring unit (emergency room, COVID-19 wards and intensive care unit (ICU)) occurred. Logistic regression analyses were used to investigate the impact of CARE, patients' age and sex on the outcome. To evaluate the prognostic performance of CARE, receiver operating characteristic curves were computed for the entire stay and at admission only.
A total of 1203 chest radiographs of 175 patients (120 males; mean age 67.81±15.5 years old) were examined. On average, each patient underwent 6.8±10.3 radiographs. Patients in ICU as well as deceased patients showed higher CARE scores (p<0.05, each). Age, Co and CARE significantly influenced the outcome (p<0.05 each). The CARE demonstrated good accuracy (area under the curve (AUC)=0.736) using longitudinal data as well as at admission only (AUC=0.740). A CARE score of 17.5 during hospitalisation showed 75% sensitivity and 69.9% specificity.
The CARE was demonstrated to be a reliable tool to assess the severity of pulmonary involvement at chest radiography with a good prognostic performance.
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