Prognosis of stroke patients undergoing mechanical ventilation

Objective To determine the outcome of stroke patients undergoing mechanical ventilation. Design Retrospective chart review and follow-up telephone interview. Setting Medical ICU in a multidisciplinary university hospital. Patients and participants 199 stroke patients from 1984–1989 where the final diagnosis was stroke. Interventions All patients were admitted for the need of mechanical ventilation. Measurements and results Demographic information, previous relevant diseases, stroke type, general clinical and neurological data, biochemical variables, severity of illness were recorded for the first 24 h following ICU admission. A 1-year follow-up was performed, including mortality and functional status of survivors. Of 170 eventually analyzable patients, 123 (72.4%) died during their ICU stay and 156 (91.8%) during the first year. Three variables were independently associated with one-year mortality: Glasgow score <10 (p<0.03), bradycardia (p<0.001), absence of brainstem reflexes (p<0.0004). Conclusion Overall prognosis of stroke needing mechanical ventilation is poor, strongly linked to symptoms of neurological impairment.     

Noninvasive vs invasive ventilation in COPD patients with severe acute respiratory failure deemed to require ventilatory assistance

Objective To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to invasive mechanical ventilation in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) meeting criteria for mechanical ventilation.Design and setting Matched case-control study conducted in ICU.Patients and intervention NIV was prospectively applied to 64 COPD patients with advanced ARF. Their outcomes were compared with those of a control group of 64 COPD patients matched on age, FEV₁, Simplified Acute Physiology Score II, and pH at ICU admission, previously treated in the same ICU with conventional invasive mechanical ventilation.Methods and results NIV failed in 40 patients who required intubation. Mortality rate, duration of mechanical ventilation, and lengths of ICU and post-ICU stay were not different between the two groups. The NIV group had fewer complications (P = 0.01) and showed a trend toward a lower proportion of patients remaining on mechanical ventilation after 30 days (P = 0.056). Compared to the control group, the outcomes of the patients who failed NIV were no different. Compared to the patients who received intubation, those who succeeded NIV had reduced mortality rate and lengths of ICU and post-ICU stay.Conclusions In COPD patients with advanced hypercapnic acute respiratory failure, NIV had a high rate of failure, but, nevertheless, provided some advantages, compared to conventional invasive ventilation. Subgroup analysis suggested that the delay in intubation was not deleterious in the patients who failed NIV, whereas a better outcome was confirmed for the patients who avoided intubation.     

Management of SARS-CoV-2 pneumonia in intensive care unit: An observational retrospective study comparing two bundles

PurposeTo compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients.Materials and methodsOur retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence.Results129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO₂/FiO₂ ratio < 125 were associated with in-hospital mortality.ConclusionWithin the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.     

Sequential use of noninvasive pressure support ventilation for acute exacerbations of COPD

Objectives: To compare the efficacy of noninvasive pressure support ventilation (NIPSV) in acute decompensation in chronic obstructive pulmonary disease (COPD) by means of a bi-level positive airway pressure support system (BiPAP) in a sequential mode with medical therapy alone; to assess the short-term physiologic effects of the device on gas exchange; and to compare patients successfully ventilated with NIPSV with those in whom NIPSV failed. Design: A prospective case series with historically matched control study. Setting: A general intensive care unit (ICU) of a university hospital. Patients: We evaluated the efficacy of administration of NIPSV in 42 COPD patients and compared this with standard treatment in 42 matched historical control COPD patients. Interventions: NIPSV was performed in a sequential mode, i. e., BiPAP in the spontaneous mode was used for at least 30 min every 3 h. Between periods of ventilation, patients could be systematically returned to BiPAP when the arterial oxygen saturation was < 0.85 or when the respiratory rate was > 30 breaths/min. Measurements and results: Success rate, mortality, duration of ventilatory assistance, and length of ICU stay were recorded. Eleven of the 42 patients (26 %) in the NIPSV group needed tracheal intubation compared with 30 of the 42 control patients (71 %). The 31 patients in whom NIPSV was successful were ventilated for a mean of 6 ± 3 days. In-hospital mortality was not significantly different in the treated versus the control group, but the duration of ventilatory assistance (7 ± 4 days vs 15 ± 10 days, p < 0.01) and the length of ICU stay (9 ± 4 days vs 21 ± 12, p < 0.01) were both shortened by NIPSV. BiPAP was effective in correcting gas exchange abnormalities. The pH values, measured after 45 min of BiPAP with optimal settings, in the success (7.38 ± 0.04) and failure (7.28 ± 0.04) patients were significantly different (p < 0.05). Conclusions: NIPSV, performed with a sequential mode, may be used in the management of patients with acute exacerbations of COPD. Received: 10 February 1997 Accepted: 14 July 1997     

Gastro-oesophageal reflux disease increases the risk of intensive care unit admittance and mechanical ventilation use among patients with chronic obstructive pulmonary disease: a nationwide population-based cohort study

IntroductionGastro-oesophageal reflux disease (GORD) is common among chronic obstructive pulmonary disease (COPD) patients and may have a deleterious effect on COPD prognosis. However, few studies have investigated whether GORD increases the risk of severe outcomes such as intensive care unit (ICU) admittance or mechanical ventilator use among COPD patients.MethodsPropensity score matching by age, sex, comorbidities and COPD severity was used to match the 1,210 COPD patients with GORD sourced in this study to 2,420 COPD patients without GORD. The Kaplan-Meier method was used to explore the incidence of ICU admittance and machine ventilation with the log rank test being used to test for differences. Cox regression analysis was used to explore the risk of ICU admittance and mechanical ventilation use for patients with and without GORD.ResultsDuring the 12-month follow-up, GORD patients and non-GORD patients had 5.22 and 3.01 ICU admittances per 1000 person-months, and 4.34 and 2.41 mechanical ventilation uses per 1000 person-month, respectively. The log rank test revealed a difference in the incidence of ICU admittance and machine ventilation between the two cohorts. GORD was found to be an independent predicator of ICU admittance (adjusted hazard ratio (HR_adj) 1.75, 95% confidence interval (CI) 1.28-2.38) and mechanical ventilation (HR_adj 1.92, 95% CI 1.35-2.72).ConclusionThis is the first investigation to detect a significantly higher incidence rate and independently increased risk of admission to an ICU and mechanical ventilation use among COPD patients who subsequently developed GORD during the first year following their GORD diagnosis than COPD patients who did not develop GORD.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0849-1) contains supplementary material, which is available to authorized users.     

Late steroid therapy in primary acute lung injury

Objective: To investigate the effect of steroid treatment in the late phase of primary acute lung injury (ALI) with special emphasis on pneumococcal pneumonia. Design: Retrospective study. Setting: Multidisciplinary intensive care unit (ICU) in a university hospital. Patients: Of 31 patients with primary ALI requiring mechanical ventilation for more than 10 days, 16 were treated with methylprednisolone and 15 served as controls. Measurements and results: Steroid and control groups were comparable regarding demographic data, APACHE II score, Multiple Organ Dysfunction Score (MODS), and PaO₂/FiO₂-ratio on admission to ICU. The mean start of steroid therapy was 9.7 days after establishment of respiratory failure, and values for control patients were registered on day 10. The PaO₂/FiO₂ ratio improved significantly within 3 days after the start of steroid therapy, and MODS and C-reactive protein decreased concurrently. No differences in mortality, in length of ICU stay, or in length of mechanical ventilation were detectable. In a subgroup analysis, for patients with Streptococcus pneumoniae pneumonia, beneficial change in physiological variables was evident. Conclusions: In patients with primary ALI, steroid therapy, started 10 days after the start of mechanical ventilation, improves gas exchange and is associated with a decrease in multiorgan dysfunction. Received: 21 July 1999 Final revision received: 1 November 1999 Accepted: 15 December 1999     

Noninvasive ventilation for the treatment of acute respiratory failure in patients with hematologic malignancies: a pilot study

Objective: To evaluate treatment with noninvasive ventilation (NIV) by nasal mask as an alternative to endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies complicated by acute respiratory failure to decrease the risk of hemorrhagic complications and increase clinical tolerance. Design: Prospective clinical study. Setting: Hematologic and general intensive care unit (ICU), University of Rome “La Sapienza”. Patients: 16 consecutive patients with acute respiratory failure complicating hematologic malignancies. Interventions: NIV was delivered via nasal mask by means of a BiPAP ventilator (Respironics, USA); we evaluated the effects on blood gases, respiratory rate, and hemodynamics along with tolerance, complications, and outcome. Measurements and results: 15 of the 16 patients showed a significant improvement in blood gases and respiratory rate within the first 24 h of treatment. Arterial oxygen tension (PaO₂), PaO₂/FIO₂ (fractional inspired oxygen) ratio, and arterial oxygen saturation significantly improved after 1 h of treatment (43 ± 10 vs 88 ± 37 mmHg; 87 ± 22 vs 175 ± 64; 81 ± 9 vs 95 ± 4 %, respectively) and continued to improve in the following 24 h (p < 0.01). Five patients died in the ICU following complications independent of the respiratory failure, while 11 were discharged from the ICU in stable condition after a mean stay of 4.3 ± 2.4 days and were discharged in good condition from the hospital. Conclusions: NIV by nasal mask proved to be feasible and appropriate for the treatment of respiratory failure in hematologic patients who were at high risk of intubation – related complications. Received: 21 April 1998 Accepted: 18 September 1998     

Pulmonary artery catheterization in exacerbations of COPD requiring mechanical ventilation: a cost-effectiveness analysis

The cost-effectiveness of pulmonary artery catheterization (PAC) has been questioned in many clinical situations. We sought to assess the cost-effectiveness of PAC in patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation. METHODS: We constructed a decision analysis model and calculated the incremental cost/quality-adjusted life-year (QALY) saved for hypothetical patients, comparing a PAC strategy to one of no PAC. Sensitivity analyses were performed to test the stability of conclusions over wide ranges of values. RESULTS: The incremental cost/QALY saved in the cost-effectiveness analysis using baseline data is $77,407 when catheterization-driven therapeutic changes result in a 5% improvement in survival. Cost-effectiveness is sensitive to variations in post-hospital life expectancy, quality of life, and the probability of favorable therapeutic changes resulting from the use of catheterization data. CONCLUSIONS: Pulmonary artery catheterization in COPD exacerbation requiring mechanical ventilation is expensive compared to accepted medical interventions for other conditions, unless changes in therapy prompted by catheterization increase hospital survival to a level 8.7% above baseline. Randomized, controlled trials are needed to investigate the economic impact of PAC and its effect on morbidity and mortality of critically ill patients.     

Noninvasive versus conventional ventilation to treat hypercapnic encephalopathy in chronic obstructive pulmonary disease

Objective We recently reported a high success rate using noninvasive positive pressure ventilation (NPPV) to treat COPD exacerbations with hypercapnic encephalopathy. This study compared the hospital outcomes of NPPV vs. conventional mechanical ventilation (CMV) in COPD exacerbations with moderate to severe hypercapnic encephalopathy, defined by a Kelly score of 3 or higher. Design and setting A 3-year prospective matched case-control study in a respiratory semi-intensive care unit (RSICU) and intensive care unit (ICU). Patients and participants From 103 consecutive patients the study included 20 undergoing NPPV and 20 CMV, matched for age, simplified acute physiology score II, and baseline arterial blood gases. Measurements and results ABG significantly improved in both groups after 2 h. The rate of complications was lower in the NPPV group than in the CMV group due to fewer cases of nosocomial pneumonia and sepsis. In-hospital mortality, 1-year mortality, and tracheostomy rates were similar in the two groups. Fewer patients remained on ventilation after 30 days in NPPV group. The NPPV group showed a shorter duration of ventilation. Conclusions In COPD exacerbations with moderate to severe hypercapnic encephalopathy, the use of NPPV performed by an experienced team compared to CMV leads to similar short and long-term survivals with a reduced nosocomial infection rate and duration of ventilation.     

Excess ICU mortality attributable to ventilator-associated pneumonia: The role of early vs late onset

Objective To determine the impact of ventilator-associated pneumonia (VAP) on ICU mortality, and whether it is related to time of onset of pneumonia. Design Prospective cohort study. Setting 16-bed medical-surgical ICU at a university-affiliated hospital. Patients and measurements From 2002 to 2003, we recorded patients receiving mechanical ventilation for > 72 h. Patients developing an infection other than VAP were excluded. Patients definitively diagnosed with VAP (n = 40) were cases and patients free of any infection acquired during ICU stay (n = 61) were controls. The VAP-attributed mortality was defined as the difference between observed mortality and predicted mortality (SAPS II) on admission. Results Mechanical ventilation was longer in VAP patients (25 ± 20 vs 11 ± 9 days; p < 0.001), as was ICU stay (33 ± 23 vs 14 ± 12 days; p < 0.001). In the non-VAP group, no difference was found between observed and predicted mortality (27.9 vs 27.4%; p > 0.2). In the VAP group, observed mortality was 45% and predicted mortality 26.5% (p < 0.001), with attributable mortality 18.5%, and relative risk (RR) 1.7 (95% CI 1.12–23.17). No difference was observed between observed and predicted mortality in early-onset VAP (27.3 vs 25.8%; p > 0.20); in late-onset VAP, observed mortality was higher (51.7 vs 26.7%; p < 0.01) with attributable mortality of 25% and an RR 1.9 (95% CI 1.26–2.63). Empiric antibiotic treatment was appropriate in 77.5% of episodes. No differences in mortality were related to treatment appropriateness. Conclusions In mechanically ventilated patients, VAP is associated with excess mortality, mostly restricted to late-onset VAP and despite appropriate antibiotic treatment.     

Ventilatory response and arterial potassium concentration during incremental exercise in patients with chronic airways obstruction

Summary. The relationship of ventilation response (V?_E) to arterial potassium concentration (K⁺) during ramp incremental exercise was assessed in nine patients with chronic obstructive pulmonary disease (COPD), and in 10 healthy subjects. For COPD patients the maximum oxygen uptake (VO_max) was 19.6±3.8 ml kg^-1 min^-1 (± SD), and percentage of forced expired volume at 1 s (% FEV₁) was 47.8 ± 10.4%. In healthy subjects, Vo₂max was 44.4±7.0 ml kg^-1 min^-1 and FEV₁, was 89.7 ± 7.4%. Breath-by-breath determinations for V?_E, oxygen uptake (V?o₂) and carbon dioxide output (V?co₂), as well as determinations for K⁺, partial pressure of oxygen (Po₂), partial pressure of carbon dioxide (Pco₂), pH and lactate in arterial blood were performed during a workout on an exercise bicycle at a ramp function work rate of 20 W min^-1, preceded by a 40 min warm-up period. The major findings in the present study are: (1) that there is a linear relation between ventilation and arterial K⁺ concentration during ramp exercise in both healthy subjects and COPD patients; (2) that the slope of the V?_E-K⁺ relationship is significantly lower in COPD patients (16.2 ± 7.31 min^-1 mM^-1) than in normal subjects (37.4 ± 6.91 min^-1 mM^-1, P<0.01); and, (3) that the slope of the V?_E-K⁺ relationship is significantly related to the ability to ventilate during maximal exercise in both healthy subjects and COPD patients (P<0.05). It is thought that the significantly reduced slope of the V?_E-K⁺ relationship in the COPD patients could be interpreted as a reduced sensitivity to the stimulus and/or as a mechanical impairment of the ventilation.     

Linear and nonlinear analysis of pressure and flow during mechanical ventilation

Objective: Linear modeling as a method of exploring respiratory mechanics during mechanical ventilation, was compared to nonlinear modeling for flow dependence of resistance in three distinct groups of patients, those with: (a) normal respiratory function (NRF), (b) chronic obstructive pulmonary disease (COPD), or (c) adult respiratory distress syndrome (ARDS). Design and patients: Airways opening pressure (Pao), flow (V′), and volume (V) signals were recorded in 32 ICU mechanically ventilated patients, under sedation and muscle relaxation (10 NRF, 11 COPD, 11 ARDS). All patients were ventilated with controlled mandatory ventilation mode at three levels of end-expiratory pressure (PEEPe): 0, 5, and 10 hPa. Data were analyzed according to: (a) Pao = PE + Ers V + Rrs V′ and (b) Pao = PE + Ers V + k ₁V′ + k ₂|V′|V′, where Ers and Rrs represent the intubated respiratory system (RS) elastance and resistance, k ₁ and k ₂ the linear and the nonlinear RS resistive coefficients, and PE the end-expiratory pressure. The model's goodness of fit to the data was evaluated by the root mean square difference of predicted minus measured Pao values. Results: NRF data fit both models well at all PEEPe levels. ARDS and particularly COPD data fit the nonlinear model better. Values of k ₂ were often negative in COPD and ARDS groups, and they increased in parallel with PEEPe. A gradual increase in PEEPe resulted in better fit of ARDS and COPD data to both models. Conclusions: The model of V′ dependence of resistance is more suitable for the ARDS and particularly the COPD groups. PEEP tends to diminish the V′ dependence of respiratory resistance during the respiratory cycle, particularly in the COPD group, probably through an indirect effect of the increased lung volume. Received: 14 June 1999 Final revision received: 19 November 1999 Accepted: 11 April 2000     

Prediction of prolonged ventilatory support in blunt thoracic trauma patients

Objective To identify predictors of prolonged (>7 days) mechanical ventilation (MV) in patients with blunt thoracic trauma.Design Prospective analysis of consecutive patients.Setting Adult intensive care unit (ICU) in a teaching, tertiary-care hospital.Patients and participants Sixty-nine patients (53 men, 16 women) with thoracic trauma having a median age of 35 (range 17–85) years and a median injury severity score (ISS) of 29 (range 14–41) were enrolled in the present study. Associated injuries included head–neck (77%), extremities (72%), external (67%), abdomen–pelvis (67%), and face (55%).Interventions Patient surveillance and data collection.Measurements and results Thirty-three (48%) of the 69 patients required prolonged ventilatory support, ranging in duration from 8 to 38 (median 18) days. Logistic regression analysis revealed that advancing age (odds ratio=1.04, p=0.04), severity of head injury (odds ratio=1.92, p=0.008), and bilateral thoracic injuries (odds ratio=12.80, p<0.0001) were significant and independent predictors of long-lasting MV. In contrast, gender, injuries affecting the other body regions (face, abdomen–pelvis, extremities, and external), laparotomy in patients with abdominal injury, or PaO₂/FIO₂ on admission in the ICU, were unrelated to prolonged MV.Conclusions In thoracic trauma patients admitted in the ICU, prolonged mechanical ventilation was primarily determined by presence of bilateral chest injuries, age, and degree of neurotrauma. This information may help in planning the long-term care of such patients.     

Timing of recovery of lung function after severe hypoxemic respiratory failure in children

Objective: To describe the timing of recovery of lung function after severe acute hypoxemic respiratory failure (AHRF) in children. Design: A serial observational follow-up study of clinical and lung function measurements up to 53 months after acute illness. Setting: University pediatric intensive care unit in a national children's hospital. Patients: Five critically ill children aged 5–14 years. Interventions: None Results: Clinical recovery: each patient required a 3–5 month convalescence before being able to attend full-time school because of lethargy and dyspnea. All patients developed wheeze 3–12 months after illness and four received long-term bronchodilator therapy. Lung function recovery: for both the forced vital capacity (FVC) and forced vital capacity in the first second (FEV₁) four patients had abnormally low values, regaining only 60–70 % of predicted values for their height and sex, and all of this improvement had occurred by 6–12 months after illness. Beyond this interval, patients remained on their same FVC and FEV₁ centile. FEV₁/FVC ratios were consistently within the normal range, indicating a predominantly restrictive defect. Changes in peak expiratory flow exhibited a time course of improvement similar to the other lung function tests. Conclusion: In children, pulmonary recovery after severe AHRF may occur for 6–12 months. A 1-year follow-up could offer a rational single point for assessment of outcome and long-term counselling of child and parents. Received: 10 November 1997 Accepted: 20 January 1998     

Adiponectin as a biomarker of systemic inflammatory response in smoker patients with stable and exacerbation phases of chronic obstructive pulmonary disease

Background and objective. Adiponectin is an adipose tissue‐derived specific protein that has a role in energy homeostasis, that has a protective role against the development of insulin resistance and atherosclerosis and that exhibits anti‐inflammatory properties. We investigated serum adiponectin as a biomarker of systemic inflammatory response and its relation with leptin, C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR) and nitric oxide (NO) in chronic obstructive pulmonary disease (COPD) patients. Material and methods. We studied 36 male patients with COPD (15 stable and 21 exacerbated) and 17 age and sex‐matched healthy subjects. The adiponectin and leptin levels were measured by enzyme‐linked immunosorbent assay. Serum CRP levels were measured using the nephelometric method. ESR was determined using the Westergren method and NO by the cadmium reduction method. Results. Adiponectin levels in COPD patients were significantly higher than those in control subjects (p<0.001), whereas there were no differences in leptin or NO levels. Serum levels of CRP, ESR and adiponectin were significantly higher in the exacerbated COPD patients compared to the stable group (p<0.001, p = 0.033 and p = 0.024, respectively), whereas the differences in leptin and NO levels were not significant. Serum levels of adiponectin were not correlated with FEV₁, FEV₁/FVC, dyspnoea score, BMI or other inflammatory parameters in the stable COPD group. CRP and ESR correlated negatively with FEV₁ in the stable COPD group. Conclusions. Adiponectin may be a marker of low‐grade systemic inflammatory response in COPD. A further rise in serum adiponectin in the exacerbation period denotes that this may also be a biomarker of the exacerbation phase as well as CRP and ESR.     

Hemodynamic and gas exchange responses to inhalation of nitric oxide in patients with the acute respiratory distress syndrome and in hypoxemic patients with chronic obstructive pulmonary disease

Objective: Inhalation of nitric oxide (NO) can improve oxygenation and decrease mean pulmonary artery pressure (MPAP) in patients with the acute respiratory distress syndrome (ARDS). It is not known whether inhaled NO exerts a similar effect in hypoxemic patients with chronic obstructive pulmonary disease (COPD). Design: Prospective clinical study. Setting: General intensive care unit in Sabadell, Spain. Patients: Nine mechanically ventilated COPD patients (mean age 72±2 years; forced expiratory volume in 1 s 0.91±0.11 l) and nine ARDS patients (mean age 57±6 years; mean lung injury score 2.8±0.1) Measurements and results: We measured hemodynamic and gas exchange parameters before NO inhalation (basal 1), during inhalation of 10 ppm NO (NO-10), and 20 min after NO was discontinued (in basal 2) in the ARDS group. In the COPD group, these parameters were measured before NO inhalation (basal 1), during different doses of inhaled NO (10, 20, and 30 ppm), and 20 min after NO was discontinued (basal 2). A positive response to NO was defined as a 20% increment in basal arterial partial pressure of oxygen (PaO₂). MPAP and pulmonary vascular resistance (PVR) decreased significantly, while other hemodynamic parameters remained unchanged after NO-10 in both groups. Basal oxygenation was higher in the COPD group (PaO₂/FIO₂ (fractional inspired oxygen) 190±18 mmHg) than in the ARDS group (PaO₂/FIO₂ 98±12 mmHg), (p<0.01). After NO-10, PaO₂/FIO₂ increased (to 141±17 mmHg, p<0.01) and Qva/Qt decreased (39±3 to 34±3%, p<0.01) in the ARDS group. There were no changes in PaO₂/FIO₂ and Qva/Qt when the NO concentration was increased to 30 ppm in the COPD group. In both groups, a correlation was found between basal MPAP and basal PVR, and between the NO-induced decrease in MPAP and in PVR. The NO-induced increase in PaO₂/FIO₂ was not correlated with basal PaO₂/FIO₂. In the ARDS group, six of the nine patients (66%) responded to NO and in the COPD group, two of nine (22%) (p=0.05). Conclusions: NO inhalation had similar effects on hemodynamics but not on gas exchange in ARDS and COPD patients, and this response probably depends on the underlying disease. Received: 19 December 1995 Accepted: 28 September 1996     

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation

Objective: We investigated whether a treatment according to a clinical algorithm could improve the low survival rates in acute respiratory distress syndrome (ARDS). Design: Uncontrolled prospective trial. Setting: One university hospital intensive care department. Patients and participants: 122 patients with ARDS, consecutively admitted to the ICU. Interventions: ARDS was treated according to a criteria-defined clinical algorithm. The algorithm distinguished two main treatment groups: The AT-sine-ECMO (advanced treatment without extracorporeal membrane oxygenation) group (n = 73) received a treatment consisting of a set of advanced non-invasive treatment options, the ECMO treatment group (n = 49) received additional extracorporeal membrane oxygenation (ECMO) using heparin-coated systems. Measurements and results: The groups differed in both APACHE II (16 ± 5 vs 18 ± 5 points, p = 0.01) and Murray scores (3.2 ± 0.3 vs 3.4 ± 0.3 points, p = 0.0001), the duration of mechanical ventilation prior to admission (10 ± 9 vs 13 ± 9 days, p = 0.0151), and length of ICU stay in Berlin (31 ± 17 vs 50 ± 36 days, p = 0.0016). Initial PaO₂/FIO₂ was 86 ± 27 mm Hg in AT-sine-ECMO patients that improved to 165 ± 107 mm Hg on ICU day 1, while ECMO patients showed an initial PaO₂/FIO₂ of 67 ± 28 mm Hg and improvement to 160 ± 102 mm Hg was not reached until ICU day 13. Q˙_S/Q˙_T was significantly higher in the ECMO-treated group and exceeded 50 % during the first 14 ICU days. The overall survival rate in our 122 ARDS patients was 75 %. Survival rates were 89 % in the AT-sine ECMO group and 55 % in the ECMO treatment group (p = 0.0000). Conclusions: We conclude that patients with ARDS can be successfully treated with the clinical algorithm and high survival rates can be achieved. Received: 9 April 1997 Accepted: 13 May 1997     

The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure

Purpose

The aim of this study was to assess the impact of the 3 types of initial respiratory support (noninvasive positive pressure ventilation vs invasive positive pressure ventilation vs supplemental oxygen only) in hematological patients with acute hypoxemic respiratory failure (ARF).

Materials and Methods

This study is a retrospective analysis of a cohort of hematological patients admitted to the intensive care unit (ICU) of a tertiary care hospital between January 1, 2002, and June 30, 2006.

Results

One hundred thirty-seven hematological patients were admitted at the ICU with ARF (defined as Pao₂/Fio₂ <200): within the first 24 hours, 24 and 67 patients received noninvasive positive pressure ventilation and invasive positive pressure ventilation, respectively, and 46 received supplemental oxygen only. Intensive care unit mortality in the 3 patient categories was 71%, 63%, and 32%, respectively (P = .001), and in-hospital mortality was 75%, 80%, and 47%, respectively (P = .001). In multivariate regression analysis, increasing cancer-specific severity-of-illness score upon admission and more organ failure after 24 hours of ICU admission, but not the type of initial respiratory support, were significantly associated with ICU or in-hospital mortality.

Conclusions

Intensive care unit and in-hospital mortality in our population of hematological patients with hypoxemic ARF was determined by severity of illness and not by the type of initial respiratory support.     

Increased Prevalence of Patent Foramen Ovale in Patients with Severe Chronic Obstructive Pulmonary Disease

This study was designed to assess the prevalence of patent foramen ovale (PFO) in patients with severe chronic obstructive pulmonary disease (COPD) and the magnitude of any effects of right-to-left interatrial PFO shunting on systemic arterial oxygen desaturation after the Valsalva maneuver. The prevalence of PFO was compared between a group of 20 patients with severe chronic obstructive pulmonary disease (FEV₁ % <50%; FEV₁ /FVC <50%) and 20 control subjects (FEV₁ % >70%; FEV₁ /FVC >70%) by contrast transesophageal echocardiography during the Valsalva maneuver with simultaneous measurement of systemic arterial oxygen saturation (SaO₂ ) by pulse oximetry. Patients with severe COPD (FEV₁ = 27.2% ± 8.4%; FEV₁ /FVC = 44.3% ± 11.0%) had a significantly higher pulmonary artery systolic pressure (38.3 ± 7.3 vs 21.0 ± 2.4 mm Hg; P < .005), higher prevalence of PFO (14/20 = 70% vs 7/20 = 35%; P < .05), and greater systemic arterial desaturation after Valsalva (Sao₂ change: –2.6% ± 1.4% vs –1.1% ± 0.9%; P < .005) than control subjects. In the severe COPD group, the degree of systemic arterial desaturation after Valsalva in patients with PFO was significantly greater than in patients without PFO (Sao₂ change: –3.1% ± 1.4% vs –1.5% ± 0.5%; P < .05). Significant systemic arterial oxygen desaturation was observed after Valsalva in 45% of patients with interatrial PFO shunting and severe COPD. This significantly correlated with the degree of pulmonary hypertension (r = 0.6; P < .05). We conclude (1) that patients with severe COPD have an increased prevalence of PFO and (2) that approximately one half of subjects with severe COPD and PFO demonstrate statistically significant systemic arterial oxygen desaturation after the Valsalva maneuver. (J Am Soc Echocardiogr 1999;12:99-105.)     

Effects of inhaled salmeterol and salbutamol (albuterol) on morning dips compared in intensive care patients recovering from an acute severe asthma attack

Objective: To assess the effect of a long-acting inhaled β ₂-agonist, salmeterol (SM), compared to a short-acting inhaled β ₂-agonist, salbutamol (or albuterol, SB), on the occurrence of morning dip (MD) in patients recovering from an acute severe asthma attack (ASA). Design: Prospective study Setting: 18-bed, medical intensive care unit (ICU) in a university hospital. Patients: 19 patients suffering from an ASA. Interventions: Serial measurements of the peak expiratory flow rate (PEFR), arterial blood gases, vital capacity and forced expiratory volume in one second (FEV₁) were performed from admission. All patients were first treated with i. v. methyl prednisolone and i. v. SB. Once the PEFR was stable and > 35 % of predicted value, i. v. SB was stopped while i. v. steroids were maintained, and patients were randomised to either inhaled SB (9 patients, 400 μg every 4 h) or inhaled SM (10 patients, 100 μg every 12 h). Results: The mean admission PEFR was 26.1 ± 11.7 % of the predicted value and was not different between the two groups. MD was more frequent with SB (6/9 patients) than with SM (4/10). The severity of MD, expressed in l/min fall in PEFR, was higher in SB than in SM (106 ± 25 vs 55 ± 37; p < 0.05). Discussion: MD is frequent in ASA. In ASA, SM appears to reduce the frequency and the severity of MD more than SB. The clinical implications of this observation, particularly a lowering of mortality and a shortening of the ICU stay, remain to be investigated. Received: 27 March 1997 Accepted: 24 September 1997