Mechanical Ventilation

Jan 082012
Early tracheostomy doesn't improve outcomes ... much (Meta-analysis, CHEST)

[poll id=”3″] A 2005 meta-analysis of 5 studies (n=406) concluded that early tracheostomy reduced need for mechanical ventilation and ICU days. But then a 2006 randomized trial in trauma patients found no benefit to early trach, and an underpowered 2008 RCT also found no benefit. In a new meta-analysis and systematic review of 7 trials (n=1,044), Fei [… read more]

Jan 082012
Elderly critically ill who survive ICU rationing live well (CHEST)

Many argue that as a limited resource serving unlimited needs, medical care is “rationed” by definition, and ICU resources (being more limited and expensive) are simply more overtly rationed. For example, in France, ICU admission is often denied to the very elderly critically ill, explicitly because of their age (this happens in the U.K., too, probably). In the U.S., [… read more]

Jan 012012

Numerous small (n~100), single-center randomized trials have shown a benefit of omega-3 fatty acids in acute lung injury and ARDS (reduced mortality, length of stay, and organ failure; improved oxygenation and respiratory mechanics). A meta-analysis combining these studies suggested a stat.significant benefit in mortality (risk ratio 0.67), ventilator requirement (-5 days), and ICU stay (-4 [… read more]

Jan 012012

Each individual episode of critical illness produces a mushroom cloud of data, most of which dissipates without being recorded at all (think realtime infusion rates of vasopressors and continuous ECG monitoring). A few large databases capture outcomes data from multiple participating hospitals (like the National Inpatient Sample), and the new MIMIC-II integrated data system can [… read more]

Dec 182011

For one year, Dallas et al prospectively followed 2,060 intubated MICU/SICU patients at Barnes-Jewish, and concluded that 83 (4%) developed VAP and 28 (1.4%) got VAT, which was defined as fever and 100,000 CFUs in tracheal secretions, without an infiltrate. By their reckoning, a third of VATs progressed to VAPs. Pathogens (mainly MDR bacteria) overlapped. [… read more]

Dec 182011

In the longest longitudinal study of acute respiratory distress syndrome (ARDS) yet, Herridge et al followed 109 young survivors of severe ARDS (medians: age 44; Lung Injury Score 3.7 out of 4) in Canada for 5 years, enrolling 1998-2001. Twelve died in the first year. At 5 years, the survivors remained below their pre-ARDS exercise tolerance; they [… read more]

Dec 102011

Severe sepsis has had a 35-45% mortality rate in clinical trials. Gagan Kumar et al use national observational data to suggest that while population rates of severe sepsis are increasing, survival has likely improved, with mortality falling from 39% to 27%, 2000-2007. However, most of the new survivors are not going home, but rather to [… read more]

Nov 222011

As Sancho et al point out here, there is a paucity of information available about tracheotomy in amyotrophic lateral sclerosis — when it’s best to perform the life-prolonging surgery, as well as what patients, families, and physicians can expect afterward. They followed 116 patients with ALS; 76 were recommended to receive tracheotomy when they could [… read more]

Nov 112011

Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]

Nov 012011

October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [… read more]

Nov 012011

The 2009 randomized CESAR trial in Lancet concluded that in severe ARDS in the U.K., referral to an ECMO center saved lives. However, patients in the control (non-ECMO) group didn’t consistently get low-tidal ventilation, and many patients randomized to ECMO never received it, creating skepticism of the findings. A case series from Australia/New Zealand (ANZ ECMO) in JAMA showed a 70% survival [… read more]

Oct 242011

Adaptive support ventilation (ASV) has entered wide use based on its attractive premise: it’s patient-centered ventilation, adapting breath-by-breath to deliver precisely the right amount of pressure support to achieve a targeted minute ventilation. However, evidence for any superiority over conventional ventilator modes is limited to cardiac surgery patients who were extubated in ~6 hours regardless of [… read more]

Oct 112011

In 2006, Medicare (we) spent 25% of our dollars on treatment for people in their last year of life. The debate rages, waged with euphemism in public and painful, conflicting emotions in private: how can we let Grandma go peacefully and with dignity, without feeling too guilty or ending up in front of a Senate subcommittee? [… read more]

Oct 072011

Non-invasive positive pressure ventilation (NIPPV or NPPV or NIV), overnight or during the day, has not been shown to help most people with stable COPD and daytime hypercarbia. Citing their own previous findings, Dreher, Windisch et al argue that’s because you can’t just use wimpy ordinary settings — you’ve got to crank that sucker to [… read more]

Aug 242011

Muscedere J. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med 2011;39:1985-1991. In short, it probably works to prevent ventilator-associated pneumonia (13 randomized trials, n=2,442. 12 were positive, pooled risk ratio 0.55, associated with 1-1.5 shorter days in the ICU and on the ventilator). So why not use [… read more]

Jun 192011

Masclans et al followed 38 patients with ARDS in 3 ICUs for 6 months. Health-related quality of life (Nottingham Test Profile) was lower than expected at 6 months, with 40% reporting limitations in daily activities mainly due to low energy, mobility and social functioning. Mild radiographic abnormalities and restrictive physiology were usually present on HRCT [… read more]

Jun 042011

Elliott et al (of ANZICS) randomized 195 survivors of >24h mechanical ventilation to get 3 home physical therapy visits and telephone support, or usual care, over the 8 weeks after hospital discharge. At 26 weeks, there was no difference in 6-minute walk, quality-of-life measures, or objective physical function measures. (n=195) Critical Care 2011;15:R142. FREE FULL [… read more]

May 152011

Prone positioning improves oxygenation in ARDS patients without improving outcome. Recruitment maneuvers do too. Rival et al prospectively tested the effects of both strategies together in 16 ARDS patients. Two extended sighs of 45 cm H2O in pressure control mode while lying prone improved PaO2/FiO2 from 98 to 166 mm Hg, without obvious adverse (or positive) effects. Critical [… read more]

May 142011

Protti et al ventilated 29 healthy pigs for 2 days, each at a point on a range of “strain” (tidal volume divided by functional residual capacity). Ventilator-induced lung injury only occurred at strains 1.5-2 or greater (tidal volumes in the >30 mL/kg range). Although pigs’ lungs are inherently different than ours, authors make the argument that mechanical [… read more]