The hypothesis that lung collapse is detrimental during the acute respiratory distress syndrome is still debatable. One of the difficulties is the lack of an efficient maneuver to minimize it.
To ...test if a bedside recruitment strategy, capable of reversing hypoxemia and collapse in > 95% of lung units, is clinically applicable in early acute respiratory distress syndrome.
Prospective assessment of a stepwise maximum-recruitment strategy using multislice computed tomography and continuous blood-gas hemodynamic monitoring.
Twenty-six patients received sequential increments in inspiratory airway pressures, in 5 cm H(2)O steps, until the detection of Pa(O(2)) + Pa(CO(2)) >or= 400 mm Hg. Whenever this primary target was not met, despite inspiratory pressures reaching 60 cm H(2)O, the maneuver was considered incomplete. If there was hemodynamic deterioration or barotrauma, the maneuver was to be interrupted. Late assessment of recruitment efficacy was performed by computed tomography (9 patients) or by online continuous monitoring in the intensive care unit (15 patients) up to 6 h. It was possible to open the lung and to keep the lung open in the majority (24/26) of patients, at the expense of transient hemodynamic effects and hypercapnia but without major clinical consequences. No barotrauma directly associated with the maneuver was detected. There was a strong and inverse relationship between arterial oxygenation and percentage of collapsed lung mass (R = - 0.91; p < 0.0001).
It is often possible to reverse hypoxemia and fully recruit the lung in early acute respiratory distress syndrome. Due to transient side effects, the required maneuver still awaits further evaluation before routine clinical application.
Hypoxemia during mechanical ventilation might be worsened by expiratory muscle activity, which reduces end-expiratory lung volume through lung collapse. A proposed mechanism of benefit of ...neuromuscular blockade in acute respiratory distress syndrome (ARDS) is the abolition of expiratory efforts. This may contribute to the restoration of lung volumes. The prevalence of this phenomenon, however, is unknown.
To investigate the incidence and amount of end-expiratory lung impedance (EELI) increase after the administration of neuromuscular blocking agents (NMBAs), clinical factors associated with this phenomenon, its impact on regional lung ventilation, and any association with changes in pleural pressure.
We included mechanically ventilated patients with ARDS monitored with electrical impedance tomography (EIT) who received NMBAs in one of two centers. We measured changes in EELI, a surrogate for end-expiratory lung volume, before and after NMBA administration. In an additional 10 patients, we investigated the characteristic signatures of expiratory muscle activity depicted by EIT and esophageal catheters simultaneously. Clinical factors associated with EELI changes were assessed.
We included 46 patients, half of whom showed an increase in EELI of >10% of the corresponding Vt (46.2%; IQR, 23.9-60.9%). The degree of EELI increase correlated positively with fentanyl dosage and negatively with changes in end-expiratory pleural pressures. This suggests that expiratory muscle activity might exert strong counter-effects against positive end-expiratory pressure that are possibly aggravated by fentanyl.
Administration of NMBAs during EIT monitoring revealed activity of expiratory muscles in half of patients with ARDS. The resultant increase in EELI had a dose-response relationship with fentanyl dosage. This suggests a potential side effect of fentanyl during protective ventilation.
Imbalances in regional lung ventilation, with gravity-dependent collapse and overdistention of nondependent zones, are likely associated to ventilator-induced lung injury. Electric impedance ...tomography is a new imaging technique that is potentially capable of monitoring those imbalances. The aim of this study was to validate electrical impedance tomography measurements of ventilation distribution, by comparison with dynamic computerized tomography in a heterogeneous population of critically ill patients under mechanical ventilation. Multiple scans with both devices were collected during slow-inflation breaths. Six repeated breaths were monitored by impedance tomography, showing acceptable reproducibility. We observed acceptable agreement between both technologies in detecting right-left ventilation imbalances (bias = 0% and limits of agreement = -10 to +10%). Relative distribution of ventilation into regions or layers representing one-fourth of the thoracic section could also be assessed with good precision. Depending on electrode positioning, impedance tomography slightly overestimated ventilation imbalances along gravitational axis. Ventilation was gravitationally dependent in all patients, with some transient blockages in dependent regions synchronously detected by both scanning techniques. Among variables derived from computerized tomography, changes in absolute air content best explained the integral of impedance changes inside regions of interest (r(2) > or = 0.92). Impedance tomography can reliably assess ventilation distribution during mechanical ventilation.
Abstract Purpose Expiratory asynchrony during pressure support ventilation (PSV) has been recognized as a cause of patient discomfort, increased workload, and impaired weaning process. We evaluated ...breathing pattern, patient comfort, and patient effort during PSV comparing 2 flow termination criteria: fixed at 5% of peak inspiratory flow vs automatic, real-time, breath-by-breath adjustment within the range of 5% to 55%. Materials and methods Randomized crossover clinical trial. Sixteen awake patients, in the process of weaning, under PSV for more than 24 hours were subjected to 3 phases of PSV, each lasting 1 hour and using 1 of the 2 aforementioned termination criteria. Results Effective pressure support during automatic adjustment (AA) was 12.5 ± 3.2 cm H2 O vs 12.5 ± 3.9 cm H2 O ( P = .9) with the fixed termination criterion, and external positive end-expiratory pressure was 6.2 ± 1.8 vs 6.8 ± 2 ( P < .05). The effective termination criterion was higher during AA (31% 23-39 vs 12% 6-23; P < .01), but without producing premature breath terminations. Pressure overshoots and alternative cycling-off were also decreased. Throughout the AA period, we observed a higher respiratory rate (24 ± 8 breaths/min vs 19 ± 6 breaths/min; P < .001), lower tidal volume (484 ± 88 mL vs 518 ± 102 mL; P < .001), and shorter inspiratory times (1.0 ± 0.3 seconds vs 1.3 ± 0.3 seconds; P < .001). Automatic adjustment was associated with lower airway occlusion pressure after 0.1 second (P0.1) (1.8 ± 0.9 cm H2 O vs 2.4 ± 1 cm H2 O; P < .01), lower pressure-time product to trigger the ventilator, and lower subjective discomfort (visual analog scale, 3.7 ± 1.3 vs 4.5 ± 1.2; P < .001). Conclusions When compared with a fixed termination criterion, the use of a variable, real-time–adjusted termination criterion improved some indices of patient-ventilator synchrony, producing better breathing pattern, less discomfort, and slightly lower patient effort during PSV.
To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit.
This was a prospective ...observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed.
There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model.
CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.
Avaliar a incidência, custos e mortalidade relacionados a doença crítica crônica (DCC) e identificar seus preditores clínicos em uma unidade de terapia intensiva geral.
Trata-se de uma coorte observacional prospectiva. Todos pacientes que recebiam tratamento de suporte por mais de 20 dias eram considerados doentes críticos crônicos. Permaneceram 453 pacientes após a aplicação dos critérios de exclusão.
A incidência de DCC foi de 11%. Permanência hospitalar, custos e mortalidade foram significativamente maiores na população com DCC. Ventilação mecânica, sepse, Glasgow escore <15, inadequada ingestão calórica e elevado índice de massa corporal foram preditores independentes para DCC em um modelo multivariado de regressão logística.
DCC abrange uma distinta população nas unidades de terapia intensiva apresentando maiores mortalidade, custos e permanência hospitalar. Alguns fatores presentes na admissão ou durante a primeira semana na unidade de terapia intensiva podem ser usados como preditores de DCC.
To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit.
This was a prospective ...observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed.
There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score < 15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model.
CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.
Avaliar a incidência, custos e mortalidade relacionados a doença crítica crônica (DCC) e identificar seus preditores clínicos em uma unidade de terapia intensiva geral.
Trata-se de uma coorte observacional prospectiva. Todos pacientes que recebiam tratamento de suporte por mais de 20 dias eram considerados doentes críticos crônicos. Permaneceram 453 pacientes após a aplicaçao dos critérios de exclusão.
A incidência de DCC foi de 11%. Permanência hospitalar, custos e mortalidade foram significativamente maiores na população com DCC. Ventilação mecânica, sepse, Glasgow escore <15,inadequada ingestão calórica e elevado índice de massa corporal foram preditores independentes para DCC em um modelo multivariado de regressão logística.
DCC abrange uma distinta população nas unidades de terapia intensiva apresentando maiores mortalidade, custos e permanência hospitalar. Alguns fatores presentes na admissão ou durante a primeira semana na unidade de terapia intensiva podem ser usados como preditores de DCC.
Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of ...this inflammatory response, called “ventilator-induced lung injury” (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.
Uno de los principales objetivos de la Universidad Tecnológica de Durango es la atención temprana de alumnos que se encuentran en alguna situación extraordinaria que afecte de manera negativa el ...rendimiento académico, teniendo como desenlace la deserción temprana, para así cumplir con el Sistema de Gestión de la Calidad de la Universidad al mejorar la eficiencia terminal y hacerla superior a la media nacional. Además, se tiene como objetivo el apoyar el Programa de Tutoría Institucional al mantener un expediente por alumno y grupos, de las situaciones y apoyo en el acompañamiento en la acción tutorial aplicada, detectando, orientando, canalizando y dando seguimiento. También se apoya al Programa Educativo Durango 2023 – 2028, promovido por el Gobierno del Estado de Durango por medio de la Secretaría de Educación el cual busca una gestión educativa centrada en la persona incrementando la eficiencia terminal en la educación superior. En el logro de este objetivo actualmente no se cuenta con ningún mecanismo automatizado para el ingreso y procesamiento de datos y la presentación de información para una búsqueda rápida y una exposición simple y entendible. Para esto un Sistema de Información Gerencial el cual presenta información de los datos almacenados y procesados en forma de reporte para los directivos presenta una gran ayuda y ventaja en la búsqueda de una correcta toma de decisiones y la consecución del objetivo.
To evaluate the usefulness of simple motor tasks such as hand grasping and tongue protrusion as predictors of extubation failure in critically ill neurological patients.
This was a prospective cohort ...study conducted in the neurological ICU of a tertiary care hospital in the city of Porto Alegre, Brazil. Adult patients who had been intubated for neurological reasons and were eligible for weaning were included in the study. The ability of patients to perform simple motor tasks such as hand grasping and tongue protrusion was evaluated as a predictor of extubation failure. Data regarding duration of mechanical ventilation, length of ICU stay, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia were collected.
A total of 132 intubated patients who had been receiving mechanical ventilation for at least 24 h and who passed a spontaneous breathing trial were included in the analysis. Logistic regression showed that patient inability to grasp the hand of the examiner (relative risk = 1.57; 95% CI: 1.01-2.44; p < 0.045) and protrude the tongue (relative risk = 6.84; 95% CI: 2.49-18.8; p < 0.001) were independent risk factors for extubation failure. Acute Physiology and Chronic Health Evaluation II scores (p = 0.02), Glasgow Coma Scale scores at extubation (p < 0.001), eye opening response (p = 0.001), MIP (p < 0.001), MEP (p = 0.006), and the rapid shallow breathing index (p = 0.03) were significantly different between the failed extubation and successful extubation groups.
The inability to follow simple motor commands is predictive of extubation failure in critically ill neurological patients. Hand grasping and tongue protrusion on command might be quick and easy bedside tests to identify neurocritical care patients who are candidates for extubation.
Avaliar a utilidade de tarefas motoras simples, tais como preensão de mão e protrusão da língua, para predizer extubação malsucedida em pacientes neurológicos críticos.
Estudo prospectivo de coorte realizado na UTI neurológica de um hospital terciário em Porto Alegre (RS). Pacientes adultos que haviam sido intubados por motivos neurológicos e que eram candidatos ao desmame foram incluídos no estudo. O estudo avaliou se a capacidade dos pacientes de realizar tarefas motoras simples como apertar as mãos do examinador e pôr a língua para fora seria um preditor de extubação malsucedida. Foram coletados dados referentes ao tempo de ventilação mecânica, tempo de internação na UTI, tempo de internação hospitalar, mortalidade e incidência de pneumonia associada à ventilação mecânica.
Foram incluídos na análise 132 pacientes intubados que haviam recebido ventilação mecânica durante pelo menos 24 h e que passaram no teste de respiração espontânea. A regressão logística mostrou que a incapacidade dos pacientes de apertar a mão do examinador (risco relativo = 1,57; IC95%: 1,01-2,44; p < 0,045) e de pôr a língua para fora (risco relativo = 6,84; IC95%: 2,49-18,8; p < 0,001) foram fatores independentes de risco de extubação malsucedida. Houve diferenças significativas entre os pacientes nos quais a extubação foi malsucedida e aqueles nos quais a extubação foi bem-sucedida quanto à pontuação obtida no Acute Physiology and Chronic Health Evaluation II (p = 0,02), pontuação obtida na Escala de Coma de Glasgow no momento da extubação (p < 0,001), abertura dos olhos em resposta ao comando (p = 0,001), PImáx (p < 0,001), PEmáx (p = 0,006) e índice de respiração rápida e superficial (p = 0,03).
A incapacidade de obedecer a comandos motores simples é preditora de extubação malsucedida em pacientes neurológicos críticos. Preensão de mão e protrusão da língua em resposta ao comando podem ser testes rápidos e fáceis realizados à beira do leito para identificar pacientes neurológicos críticos que sejam candidatos à extubação.
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