Severity of illness and outcome in adult patients with primary varicella pneumonia

BACKGROUND: Varicella pneumonia is a serious complication of primary varicella infection in adults that often results in respiratory failure and death. OBJECTIVE: To analyze the clinical and laboratory manifestations of primary varicella pneumonia in patients admitted to our intensive care unit (ICU). METHODS: Retrospective study on patients treated in our ICU with a diagnosis of primary varicella pneumonia during a period of 15 years. We recorded age, gender, smoking habits, clinical and laboratory findings, arterial blood gases, chest radiograph, illness severity (SAPS II), length of stay, necessity for mechanical ventilation, complications, therapy and survival. We examined the influence of the duration of respiratory symptoms and rash prior to admission, and the influence of illness severity on outcome. RESULTS: There was a statistically significant difference in duration of respiratory symptoms, duration of rash and SAPS II on admission between: (a) mechanically ventilated patients vs. spontaneously breathing patients (p < 0.007, p < 0.00, p < 0.00), (b) patients who survived vs. patients with poor outcome (p < 0.001, p < 0.000, p < 0.000), and (c) mechanically ventilated patients with poor outcome vs. mechanically ventilated patients who survived (p < 0.001, p < 0.00, p < 0.000). Overall mortality was 13.6%; death occurred only in mechanically ventilated patients (mortality 33.3%). CONCLUSIONS: Primary varicella pneumonia remains a critical problem with significant mortality. When recognized before respiratory failure ensues and mechanical ventilation becomes mandatory, patients could have an excellent outcome. Adult patients who delay asking for medical support, the disease may lead to the need for mechanical ventilation and severe complications with a fatal outcome.     

Lack of influence of gender on outcomes of mechanically ventilated medical ICU patients.

STUDY OBJECTIVES: Recent studies combining medical and surgical patients have suggested that mortality is higher for mechanically ventilated women than for men. This study was designed to determine whether there are gender-based differences in outcomes in mechanically ventilated medical ICU (MICU) patients. DESIGN AND SETTING: Prospective observational study in an MICU of a tertiary-care academic medical center. PATIENTS: Five hundred eighty consecutive patients admitted to the MICU service and mechanically ventilated for a minimum of 12 h. RESULTS: There was no difference in overall hospital mortality rate (woman, 36.3%; men, 40.4%; p > 0.2). No differences in mortality rates were noted after stratification based on age, underlying comorbid condition, APACHE (acute physiology and chronic health evaluation) II score, indication for mechanical ventilation, or acute hepatic or renal failure. Using a multiple logistic regression model, gender was not independently associated with hospital mortality. No differences were found between men and women for a number of secondary outcomes, including likelihood of undergoing weaning trials, success of weaning trials, time between onset of mechanical ventilation and extubation, total time on mechanical ventilation, rate of unplanned extubations, need for reintubation or tracheostomy, or duration of MICU and hospital stay, after the onset of mechanical ventilation. The number and timing of orders written to withhold care were comparable between men and women. CONCLUSIONS: Using univariate and multivariate analyses, we found no differences in hospital mortality rates between mechanically ventilated men and women. Differences in the process of care or gender-based treatment bias may explain previously reported differences in outcomes.     

机械通气患者营养支持应用探讨

目的比较机械通气的患者肠内与肠外营养的效果与优缺点。方法选择呼吸监护室的呼吸衰竭行机械通气患者60例,随机分为肠内营养组（治疗组n=30）与肠外营养组（对照组n=30）。治疗组给予瑞高,对照组给予一般静脉营养支持治疗。对比两组血气、营养指标变化、撤机、住ICU与营养支持时间和并发症发生情况。结果除住ICU时间治疗组短于对照组（P〈0．05）外,其余指标两组无显著性差异。患者肠内与肠外营养一样可取得较好疗效,但肠内营养方便,并发症较轻,可缩短住ICU时间,是花费低、效果好的营养支持途径。     

The effect of Shiatsu massage on agitation in mechanically ventilated patients: A randomized controlled trial

BackgroundPatients admitted to the intensive care units encounter many complications due to the nature of the disease and invasive medical procedures such as intubation and mechanical ventilation. Among these complications, agitation is a frequently-observed and serious problem.ObjectivesThis study aimed to investigate the effect of Shiatsu massage on agitation in mechanically ventilated patients.MethodsIn this randomized controlled trial, a total of 68 mechanically ventilated patients were selected and then randomly assigned to two groups of intervention and control. Patients in the intervention group received three 5-minute periods of Shiatsu massage with a 2-minute break between them, while patients in the control group only received a touch on the area considered for the message. Data were collected before and after the intervention using the Richmond Agitation-Sedation Scale (RASS) and then analyzed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA).ResultsThe results showed that the level of agitation significantly decreased in the intervention group compared to the control group (p=.001).ConclusionApplication of shiatsu massage seems to be effective in managing agitation in mechanically ventilated patients. Further studies with greater sample size and longer follow-up period are needed to confirm the current findings.     

Clinical characteristics and outcomes of mechanically ventilated elderly patients in intensive care units: a Chinese multicentre retrospective study

BackgroundIn recent years, the number of elderly patients receiving mechanical ventilation (MV) in intensive care units (ICUs) has increased. However, the evidence on the outcomes of elderly mechanically ventilated patients is scant in China. Our objective was to evaluate the characteristics and outcomes in elderly patients (≥65 years) receiving MV in the ICU.MethodsWe performed a multicentre retrospective study involving adult patients who were admitted to the ICU and received at least 24 hours of MV. Patients were divided into three age groups: under 65, 65–79, and ≥80 years. The primary outcome was hospital mortality. We performed univariate and multivariate logistic regression analysis to identify factors associated with hospital mortality.ResultsA total of 853 patients were analysed. Of those, 61.5% were ≥65 years of age, and 26.0% were ≥80 years of age. There were significant differences in the principal reason for MV among the three age groups (P<0.001). Advanced age was significantly associated with total duration of MV, ICU length of stay (LOS), and ICU costs (all P<0.001), but not with hospital LOS and hospital costs (P>0.05). In addition, mortality rates in the ICU, hospital, and at 60 days significantly increased with age (all P<0.001). In the age group of 80 years and older, the mortality rates were 47.7%, 49.5%, and 50.0%, respectively. Multivariate logistic regression analysis had found that age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO₂/FiO₂) ratio, total duration of MV, ICU LOS, and the decision to withhold/withdraw life-sustaining treatments were independent influence factors for mortality rates.ConclusionsMechanically ventilated elderly patients (≥65 years) have a higher ICU and hospital mortality, but the hospital LOS and hospital costs are similar to younger patients. Advanced age should be considered as a significant independent risk factor for hospital mortality of mechanically ventilated ICU patients.     

Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome.

The aim of this study was to determine the incidence, the organisms responsible for and the impact on outcome of nosocomial tracheobronchitis (NTB) in the intensive care unit (ICU). This prospective observational cohort study was conducted in a 30-bed medical/surgical ICU over a period of 6.5 yrs. All patients ventilated for >48 h were eligible. Patients with nosocomial pneumonia (NP) without prior NTB were excluded. Patients with first episodes of NTB were compared with those without NTB by univariate analysis. The study diagnosed 201 (10.6%) cases of NTB. Pseudomonas aeruginosa was the most common bacteria. NP rates were similar in patients with NTB compared with patients without NTB. Even in the absence of subsequent NP, NTB was associated with a significantly higher length of ICU stay and duration of mechanical ventilation in both surgical and medical populations. Mortality rates were similar in NTB patients without subsequent NP compared with patients without NTB. Antimicrobial treatment in NTB patients was associated with a trend to a better outcome. Nosocomial tracheobronchitis is common in mechanically ventilated intensive care unit patients. In this population, nosocomial tracheobronchitis was associated with longer durations of intensive care unit stay and mechanical ventilation. Further studies are needed to determine the impact of antibiotics on outcomes of patients with nosocomial tracheobronchitis.     

Analysis of risk factors of prolonged mechanical ventilation in patients with severe burn injury

Background

Mechanical ventilation is an essential means of life support for patients with severe burns. However, prolonged mechanical ventilation (PMV) increases the incidence of complications and length of hospital stay. Therefore, studying the risk factors of mechanical ventilation duration is of great significance for reducing the duration of mechanical ventilation, reducing related complications, and improving the success rate of severe burn treatment.

Method

This study was a retrospective study of patients with burns ≥30% of the area admitted to the BICU of Guangzhou Red Cross Hospital affiliated with Jinan University from January 2016 to January 2023 who were mechanically ventilated. Patients were classified into the prolonged mechanical ventilation group if they were mechanically ventilated for ≥21 days. Then, independent risk factors for prolonged mechanical ventilation were determined by logistic regression analysis of the collected data.

Result

Of all the 112 enrolled patients, 79 had prolonged mechanical ventilation, with an incidence of 70.5%. Logistic regression analysis revealed that including abbreviated burn severity index (ABSI%) (P < 0.001), moderate and severe inhalation injury (P = 0.005, P = 0.044), albumin (P = 0.032), lactic acid (P < 0.001) were independent risk factors for prolonged mechanical ventilation. In addition, ventilator-related complications were 44% in the PMV group and 21% in the non-PMV group.

Conclusion

ABSI%, inhalation injury, albumin, and lactic acid on admission are the risk factors for PMV in severe burn patients. In addition, ventilator-related complications were higher in group PMV than in group non-PMV in our study.     

Risk factors for morbidity in mechanically ventilated patients with acute severe asthma.

Acute severe asthma is associated with significant morbidity and mortality. We retrospectively quantified hypotension, pulmonary barotrauma, and cardiac arrhythmias in all patients with severe asthma admitted to the intensive care unit (ICU) and prospectively evaluated the predictive value of a measurement of dynamic hyperinflation (DHI) in those patients who required mechanical ventilation. In the first study, 88 ICU admissions for severe asthma over 5 yr (73 patients, 40 +/- 18 yr, 36 men, 37 women) were evaluated. Fifty-one admissions were mechanically ventilated, 29 were not, and 8 previously ventilated patients remained briefly intubated but were not ventilated in the ICU. Hypotension (18/88, 20%), pulmonary barotrauma (12/88, 14%), and arrhythmias (9/88, 10%) were entirely confined to patients who had been mechanically ventilated. There were no significant differences in ventilatory parameters, airway pressures, or blood gases between mechanically ventilated patients with and without complications. Two patients with previous severe hypoxic cerebral damage died from this complication after ICU discharge. In the second study, the end-inspiratory lung volume (VEI) (1) was compared with standard ventilatory parameters in 22 patients. There were no ICU deaths, but high incidences of pulmonary barotrauma (27%) and hypotension (41%) were found. Both minute ventilation (VE and VEI) were significantly higher in patients who developed complications (VE 13.7 +/- 3.0 versus 11.2 +/- 2.5 L/min, VEI 26.1 +/- 4.7 versus 20.0 +/- 7.4 ml/kg, p less than 0.05) but only VEI had a threshold value significantly predictive of complications. For VEI less than 1.4 L, 0/5 (0%) patients had complications; for VEI greater than or equal to 1.4 L, 11/17 (65%) had complications (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulmonary Mechanics Following Albuterol Therapy in Mechanically Ventilated Infants with Bronchiolitis

Background and aims. Bronchiolitis is a common cause of critical illness in infants. Inhaled β₂-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. Materials and methods. We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. Results: Fifty-four infants were enrolled. The median age was 44 days (25–75%; interquartile range (IQR) 29–74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. Conclusions. In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.     

Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU

STUDY OBJECTIVES: To determine whether there is any difference in diagnostic, therapeutic, and outcome efficacy between protocols utilizing daily (ie, routine) chest radiographs (CXRs) and those utilizing clinically indicated (ie, nonroutine) CXRs in mechanically ventilated patients. DESIGN: Prospective, randomized, observational study. SETTING: A 20-bed medical ICU at a university hospital. PATIENTS: Adult patients who had been receiving mechanical ventilation for > 48 h. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Ninety-four patients who had been intubated for at least 48 h were randomized to receive either routine or nonroutine CXRs and were observed until extubation or death. The percentage of CXRs with new findings was significantly larger in the nonroutine CXR group (53.1%; 120 CXRs) compared to that in the routine CXR group (33.4%; 98 CXRs; odds ratio [OR], 1.59; 95% confidence interval [CI], 1.16 to 2.18; p = 0.004). The number of CXRs with new findings that resulted in interventions was significantly larger in the nonroutine CXR group (26.5%; 60 CXRs) compared to that in the routine CXR group (13.3%; 39 CXRs; OR, 2.0; 95% CI, 1.29 to 3.08; p = 0.002). There was no difference in the mean duration of mechanical ventilation (routine CXR arm, 7.93 days; nonroutine CXR arm, 6.76 days; p = 0.2606), length of ICU stay (routine CXR arm, 11.93 days; nonroutine CXR arm, 9.55 days; p = 0.1936), and total length of hospital stay (routine CXR arm, 19.34 days; nonroutine CXR arm, 16.45 days; p = 0.2199) between the two groups. Although patients in the nonroutine arm of the study received fewer CXRs, adverse outcomes (eg, length of mechanical ventilation, length of hospital stay, length of ICU stay, and mortality) did not increase (p = 0.818). Using the number of CXRs per patient as a surrogate, there was a statistically significant cost savings and decreased radiation exposure in the nonroutine CXR group. CONCLUSIONS: For mechanically ventilated patients, a strategy calling for daily routine CXRs compared to CXRs obtained based on clinical indications alone was not associated with reduced ICU or hospital length of stay or with reduced mortality.     

Pneumonia due to Haemophilus influenzae among mechanically ventilated patients. Incidence, outcome, and risk factors.

Incidence and potential risk factors for pneumonia due to Haemophilus influenzae in adults treated with mechanical ventilation in a medical-surgical ICU were investigated. Diagnosis was established in 91 episodes and H influenzae was isolated in 20 of them. Mean onset of ventilator-associated pneumonia (VAP) due to H influenzae was 10.8 days after intubation. Six patients with H influenzae VAP died in the ICU. Of 13 risk factors for developing VAP due to H influenzae, an absence of prior antibiotic treatment was the only variable which had statistical significance (p < 0.001). In these mechanically ventilated patients, Haemophilus influenzae was a common causative agent for VAP, frequently associated with Gram-positive cocci. Episodes of H influenzae VAP were associated with a lower mortality compared with other etiologies. The epidemiologic and clinical findings indicate that patients without a prior antimicrobial treatment have increased susceptibility to infections of the airway by H influenzae.     

Pulmonary mechanics following albuterol therapy in mechanically ventilated infants with bronchiolitis

Background and aims. Bronchiolitis is a common cause of critical illness in infants. Inhaled β(2)-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. Materials and methods. We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. Results: Fifty-four infants were enrolled. The median age was 44 days (25-75%; interquartile range (IQR) 29-74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. Conclusions. In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.     

Functional disability and post-traumatic stress disorder in survivors of mechanical ventilation: a cross-sectional study in Guangzhou,China

BackgroundCritical illness is associated with cognitive, physical, and psychological impairments; however, evidence of the severity and frequency of impairments in Chinese survivors of mechanical ventilation in an intensive care unit (ICU) remains limited. Our aim was to investigate the incidence and severity of impairments in Chinese survivors of mechanical ventilation in ICU and to explore risk factors influencing specific impairments.MethodsPatients discharged alive after mechanical ventilation in a large general ICU for ≥2 days were enrolled in this single-center cross-sectional study. Survivors were evaluated using measures of functional disability (Activity of Daily Living Scale), and post-traumatic stress disorder (PTSD, The Impact of Event Scale-Revised) via telephone interview. Multivariable analysis was conducted.ResultsData were obtained from 130 consenting survivors. At follow-up (mean: 19.64 months), among those in part-time or full-time employment prior to admission, only 45.1% had returned to work. Further, 29.2% of survivors had clear disabilities affecting daily living. Deficits in activities of daily living (ADL) were mainly characterized by impairment of instrumental ADL. Predictors of ADL in mechanically ventilated survivors included age, ICU admission diagnosis, and Acute Physiology And Chronic Health Evaluation II (APACHE II) score, which accounted for 33.5% of total variance. Furthermore, 17.7% of participants had symptoms consistent with PTSD. ICU length of stay was the only predictor of PTSD, and accounted for 7.5% of total variance.ConclusionsICU survivors of mechanical ventilation in China face negative impacts on employment, and commonly have ADL impairment and PTSD. Age, ICU admission diagnosis, and APACHE II score were key factors influencing ADL, while ICU length of stay was the only factor affecting PTSD. These findings suggest that some survivors who have had certain exposures may warrant closer follow-up, and systematic interventions for these high-risk survivors should be developed in China.     

Safe intrahospital transport of critically ill ventilator-dependent patients

STUDY OBJECTIVE: To determine whether manual ventilation during intrahospital transport of mechanically ventilated critically ill patients results in blood gas and/or hemodynamic abnormalities. DESIGN: A single-blind prospective study evaluated arterial blood gas, blood pressure, heart rate, and arrhythmia changes during mechanical ventilation and manual transport ventilation. SETTING: University hospital ICUs and various diagnostic or treatment areas. PATIENTS: Twenty mechanically ventilated critically ill patients during intrahospital transport. INTERVENTION: Each patient received mechanical ventilation (MECH) with a volume ventilator while in the ICU and at the study/treatment area. They were manually ventilated (MAN) by a respiratory therapist during transport between areas. MEASUREMENTS AND MAIN RESULTS: The MECH settings were: VT = 0.75 +/- 0.17 L; f = 16 +/- 4; VE = 12.6 +/- 4.3 L/min; FIO2 = 0.46 +/- 0.2. Mean peak Paw = 31 +/- 12 cm H2O and mean effective Cst = 44 +/- 15 ml/cm H2O. No hemodynamic abnormalities were observed. Arterial blood gas values did not vary to any clinically significant degree, except in two patients: one patient had a reduced PaO2 and increased PaCO2 associated with an accidental O2 disconnection and clamped chest tube; another patient had an increased pH by 0.13 units with only a 9 mm Hg fall in PaCO2. CONCLUSIONS: Manual ventilation during intrahospital transport of critically ill mechanically ventilated patients is safe provided the person performing manual ventilation knows the inspired oxygen fraction and minute ventilation required before transport and is trained to approximate them during transport.     

Approach to patients with long-term weaning failure

Efforts to treat reversible disease processes that contribute to ventilator dependency in the intensive care unit (ICU) fail in up to 20% of patients, resulting in prolonged mechanical ventilation (PMV). Resolution of the insults that necessitated ICU admission and mechanical ventilation may be incomplete, and the economic pressure to transfer patients is ever increasing. The choice of post-ICU disposition depends on the patient's clinical condition, the resources of the transfer destination, and whether weaning attempts will continue. This article reviews data from a decade of weaning beyond the ICU, including outcomes of more than 2700 patients with PMV afforded continued attempts at liberation in long-term acute care facilities and other post-ICU weaning venues. Assessment and treatment, weaning strategies, and complications of patients with PMV are described.     

ICU肺部感染者应用无创机械通气的效果

摘要 目的 探讨无创机械通气在治疗ICU肺部感染患者的临床疗效。方法 分析80例重症肺炎患者的临床资料，根据呼吸支持技术分为无创机械通气组（NIPPV组）和有创机械通气组（IV组）各40例,比较两组的心率、血压、血气分析指标以及机械通气时间、ICU住院时间以及生存率。结果　经治疗两组患者的心率、血压、血气分析指标均有明显改善，但治疗后两组差异无统计学意义（P>0.05）；NIPPV组的呼吸机辅助呼吸的时间、ICU住院时间均少于IV组，差异有统计学意义（P<0.05），同时NIPPV组的生存率为72.5%，高于IV组的60%，差异同样具有统计学意义（P<0.05）。结论　采用无创机械通气治疗ICU肺部感染患者可获得与有创通气相似的效果，同时可以减少气管插管率，缩短机械通气时间，提高总体生存率。     

Tracheostomy for COVID-19 respiratory failure: timing,ventilatory characteristics,and outcomes

BackgroundWhereas data from the pre-pandemic era have demonstrated that tracheostomy can accelerate liberation from the ventilator, reduce need for sedation, and facilitate rehabilitation, concerns for healthcare worker safety have led to disagreement on tracheostomy placement in COVID-19 patients. Data on COVID-19 patients undergoing tracheostomy may inform best practices. Thus, we report a retrospective institutional cohort experience with tracheostomy in ventilated patients with COVID-19, examining associations between time to tracheostomy and duration of mechanical ventilation in relation to patient characteristics, clinical course, and survival.MethodsClinical data were extracted for all COVID-19 tracheostomies performed at a quaternary referral center from April-July 2020. Outcomes studied included mortality, adverse events, duration of mechanical ventilation, and time to decannulation.ResultsAmong 64 COVID-19 tracheostomies (13% of COVID-19 hospitalizations), patients were 64% male and 42% African American, with a median age of 54 (range, 20–89). Median time to tracheostomy was 22 (range, 7–60) days and median duration of mechanical ventilation was 39.4 (range, 20–113) days. Earlier tracheostomy was associated with shortened mechanical ventilation (R²=0.4, P<0.01). Median decannulation time was 35.3 (range, 7–79) days. There was 19% mortality and adverse events in 45%, mostly from bleeding in therapeutically anticoagulated patients.ConclusionsTracheostomy was associated with swifter liberation from the ventilator and acceptable safety for physicians in this series of critically ill COVID-19 patients. Patient mortality was not increased relative to historical data on acute respiratory distress syndrome (ARDS). Future studies are required to establish conclusions of causality regarding tracheostomy timing with mechanical ventilation, complications, or mortality in COVID-19 patients.     

The feasibility of conducting clinical trials in infants and children with acute respiratory failure

Designing robust clinical trials in critically ill, mechanically ventilated children requires an understanding of the epidemiology and course of pediatric respiratory failure. As part of a clinical trial, we screened all mechanically ventilated children in nine large pediatric intensive care units (ICUs) across North America for 6 consecutive months. Of 6,403 total ICU admissions, 1,096 (17.1%) required mechanical ventilator support for a minimum of 24 hours. Of these, 701 (64%) met one or more exclusion criteria for trial enrollment. Common reasons for exclusion were upper airway obstruction (13.5%) and cyanotic congenital heart disease (11.5%). Life support interventions were restricted for 9.7% of patients, and 5.5% were chronically ventilator dependent. In the patients who were eligible for respiratory failure studies, 62.4% had an acute primary diagnosis of pulmonary disease, 14.2% neurologic disease, and 8.9% cardiac disease. Chronic underlying conditions were present in 43.2% of the patients. The most common acute diagnosis was bronchiolitis in infants (43.6%) and pneumonia in children 1 year old and older (24.5%). Mortality was rare (1.6%), and the median duration of ventilation was 7 days. The design of clinical trials in critically ill children is feasible but must account for the diverse population, infrequent mortality, and short duration of mechanical ventilation.     

Objektive, quantitative Messung des therapeutisch-pflegerischen Aufwandes für die Beatmungsbehandlung in der internistischen Intensivmedizin

Mechanical ventilation as the key procedure in the management of respiratory failure is considered to consume a significant amount of intensive care resources. Scoring systems have gained an important role for objectively assessing resource use, quality control and stratification of study populations in intensive care medicine. The aim of our study was the objective and quantitative measurement of the therapeutic as well as the nursing workload for mechanical ventilation due to respiratory failure in medical intensive care medicine employing the simplified Therapeutic Intervention Scoring System (TISS)-28. Particularly we focused our attention on the technique of non-invasive ventilation (NIV). Therefore the TISS-28 scores were determined on each ICU day in 80 mechanically ventilated patients in a medical ICU (844 ICU days determined in total). 40 patients were on NIV and 40 patients were on conventional mechanical ventilation following endotracheal intubation, respectively. In addition in all patients the APACHE II score was determined on the first ICU day for assessment of severity of illness. Study inclusion of the NIV patients was performed in a consecutive manner, whereas the conventionally ventilated patients were included in the study based on the criterion of equivalence of disease severity compared to the NIV patients (APACHE II matching). Furthermore the number of nurses available for the ICU patients assessed by the scoring systems were counted per shift and per day, respectively, in order to obtain information concerning the number of TISS-28 scoring points, which can be managed by one critical care nurse per shift. Overall 21 218 TISS-28 scoring points were counted on the 844 ICU days for the 80 patients on mechanical ventilation. A mean value of 25.1 TISS-28 points per ICU day was calculated for each patient. Each nurse was capable of delivering care equal to 51.6 TISS-28 scoring points/d in her shift. This almost exactly matches with the nursing workload required for 2 patients on mechanical ventilation due to respiratory failure. Finally, 1 TISS-28 point/d equals a value of 9.3 min of workload in each nurse’s shift. Using NIV the mean TISS-28 score (24.1 points/d) was only slightly lower compared to conventional invasive ventilation (25.8 points/d). However, the duration of ventilation was much shorter in the NIV group (mean 5.1 days; ICU stay 8.2 days) compared to the conventional ventila tion group (mean 10.4 days; ICU stay 12.9 days). Therefore – based on scoring results – the overall nursing workload in the NIV group (7905 TISS points) was much lower compared to the overall nursing workload required for the ICU treatment of an identical number of patients in the conventional ventilation group (13 313 TISS-28 points). In conclusion, our study demonstrates that the easily and quickly accessible TISS-28 scoring system is a sophisticated instrument for the objective assessmentof therapeutic as well as nursing workload for mechanical ventilation in medical intensive care medicine. Knowledge ofsuch data is becoming increasingly important because decisions concerning resource allocation, nursing capacities as well as numbers of ICU beds are increasingly based on objective measurements like TISS-28.     

Outcomes of Ventilated COPD Patients with Nosocomial Tracheobronchitis: A Case-Control Study

Abstract. Background: The aim of this study was to determine the impact of nosocomial tracheobronchitis (NTB) related to new bacteria on the outcome in patients with chronic obstructive pulmonary disease (COPD). Patients and Methods: A prospective observational case-control study was conducted in medical COPD patients requiring intubation and mechanical ventilation for more than 48 hours. Patients with nosocomial pneumonia were excluded. Six matching criteria were used, including the duration of mechanical ventilation before NTB occurrence. Results: 81 matched case-control pairs were studied. Although the mortality rate was similar (40% vs 34%; p = 0.48), median duration of mechanical ventilation (20 vs 12 days; p = 0.015) and intensive care unit (ICU) stay (25 vs 18 days; p = 0.022) were higher in cases than in controls. NTB was independently associated with a longer than median period of mechanical ventilation among case and control patients (OR = 4.7 [95%CI = 2–10.9]; p < 0.001). In cases with appropriate antibiotic treatment compared with those who did not receive antibiotics, a shorter median duration of mechanical ventilation (12 vs 23 days; p = 0.006) and ICU stay (16 vs 29 days; p = 0.029) were observed. Conclusion: NTB is associated with an increased duration of mechanical ventilation and ICU stays. Further studies are required to determine whether antibiotics could improve the outcome of patients with NTB.