Iron lung vs mask ventilation in the treatment of acute on chronic respiratory failure in COPD patients: a multicenter study.

STUDY OBJECTIVES: Evaluation of the effectiveness of negative-pressure ventilation (NPV) with the use of the iron lung vs noninvasive positive-pressure ventilation (NIPPV) in the treatment of COPD patients with acute on chronic respiratory failure. DESIGN: A retrospective case-control study. SETTING: Four Italian respiratory intermediate ICUs. PATIENTS: Of a total of 393 COPD patients admitted to the ICU in 1996, 53 pairs were treated with the iron lung (NPV group). Patients treated with NIPPV (NIPPV group) were matched according to mean (+/- SD) age (70.3 +/- 7.1 vs 70.3 +/- 6.9 years, respectively), sex, causes of acute respiratory failure (ARF), APACHE (acute physiology and chronic health evaluation) II score (22.4 +/- 5.3 vs 22.1 +/- 4.6, respectively), pH (7.26 +/- 0.05 vs 7.27 +/- 0.04, respectively), and PaCO(2) (88.1 +/- 11.5 vs 85.1 +/- 13.5 mm Hg, respectively) on admission to the ICU. The effectiveness of matching was 98.4%. RESULTS: Five patients from the NPV group (9.4%) and seven patients from the NIPPV group (13.2%) needed endotracheal intubation (EI). The treatment failure rate (ie, death and/or need of EI) was 20.7% in the NPV group and 24.5% in the NIPPV group (difference was not significant). The mean duration of mechanical ventilation (29.6 +/- 28.6 vs 62.3 +/- 35.7 h, respectively) and length of hospital stay (10.4 +/- 4.3 vs 15 +/- 5.2 d, respectively) among the 35 concordant surviving pairs were significantly lower in the NPV group than in the NIPPV group (p = 0.001 and p = 0.001, respectively). CONCLUSIONS: These data suggest that both ventilatory techniques are equally effective in avoiding EI and death in COPD patients with ARF. Prospective trials are needed to confirm these preliminary results.     

Predictors of hospital outcome and intubation in COPD patients admitted to the respiratory ICU for acute hypercapnic respiratory failure

BACKGROUND: Mortality rate, the possible factors affecting mortality and intubation in patients with acute exacerbation of chronic obstructive pulmonary diseases (COPD) and hypercapnic respiratory failure (RF) are yet unclear. OBJECTIVE: To identify the possible factors affecting mortality and intubation in COPD patients. DESIGN: A prospective study using data obtained over the first 24h of respiratory intensive care unit (RICU) admission. Consecutive admissions of 656 patients were monitored and 151 of them who had acute exacerbation of COPD and hypercapnic RF were enrolled. SETTING: University hospital, Department of Chest Diseases, RICU. RESULTS: Mean age was 65.1 years. The mean APACHE II score was 23.7. Eighty-seven patients (57.6%) received mechanical ventilation (MV) via an endotracheal tube for more than 24 h. Twenty-two patients received non-invasive ventilation (NIV). Fifty patients died (33.1%) in hospital during the study period. The mortality rate was 52.9% in patients in need of MV. In the multivariate analysis, the need for intubation, inadequate metabolic compensation for respiratory acidosis, and low (=bad) Glasgow Coma Score (GCS) were determined as independent factors associated with mortality. The low GCS (OR: 0.61; CI: 0.48-0.78) and high APACHE II score (OR: 1.24; CI: 1.11-1.38) were determined as factors associated with intubation. CONCLUSION: The most important predictors related to hospital mortality were the need for invasive ventilation and complications to MV. Adequate metabolic compensation for respiratory acidosis at admittance is associated with better survival. A high APACHE II score and loss of consciousness (low GCS) were independent predictors of a need to intubate patients.     

In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study

STUDY OBJECTIVES: The prognosis of patients with COPD requiring admission to the ICU is generally believed to be poor. There is a paucity of long-term survival data. We undertook a study to examine both the in-hospital and 5-year mortality rates and to identify the clinical predictors of these outcomes. DESIGN: We conducted a retrospective cohort study of 57 patients admitted to the ICU between January 1999 and December 2000 for acute respiratory failure attributable to COPD. RESULTS: The mean (+/-SD) age of the study population was 70 +/- 8 years. More than 90% of patients required intubation, and the mean duration of mechanical ventilation (MV) was 2.3 +/- 2.2 days. The in-hospital mortality rate for the entire cohort was 24.5%. The mortality rates at 6 months and 1, 3, and 5 years were 39.0%, 42.7%, 61.2%, and 75.9%, respectively, following admission to the ICU. The median survival time for all patients was 26 months. The mortality rate at 5 years was 69.6% for patients who were discharged alive from the hospital. Using multivariate analysis, hospital mortality correlated positively with age, previous history of MV, long-term use of oral corticosteroids, ICU admission albumin level, APACHE (acute physiology and chronic health evaluation) II score, and duration of hospitalization. No factors predictive of mortality at 5 years were identified. CONCLUSIONS: We support previous findings of good early survival and significant but acceptable long-term mortality rates in patients who have been admitted to the ICU for acute exacerbation of COPD. Increased age, previous history of MV, poor nutritional status, and higher APACHE II score on ICU admission could be identified as risk factors associated with increased mortality rates. Long-term survival of patients with COPD who required MV for an acute exacerbation of their disease cannot be predicted simply from data available at the time of intubation. Physicians should incorporate these factors in their decision-making process.     

Procalcitonin as a prognostic factor in severe acute exacerbation of chronic obstructive pulmonary disease

Background and objective:   Little is known about the value of procalcitonin in predicting mortality in patients with an exacerbation of COPD. This study evaluated the clinical and biological predictors of intensive care unit (ICU) mortality in patients with a severe acute exacerbation of COPD.
Methods:   A prospective observational cohort study was conducted of consecutive patients with severe acute exacerbation of COPD requiring intubation and mechanical ventilation. At ICU admission, data were collected on the patients' clinical condition, blood leukocyte count, C-reactive protein and procalcitonin. Cox proportional hazards model was used to determine the risk factors for ICU mortality.
Results:   One hundred and sixteen patients were included in this study. Mean age was 67 years. The mean simplified acute physiology score was 43. Sixty-five per cent of study patients had chronic respiratory insufficiency. Bacteria were cultured at levels considered significant in 36% of study patients. Logistic organ dysfunction score (hazard ratio (95% CI) = 1.19 (1.03–1.37), P  = 0.013), rapidly fatal underlying disease (3.33 (1.40–7.87), P  = 0.003) and procalcitonin level (1.01 (1–1.03), P  = 0.018) were independently associated with increased risk for ICU mortality. Non-invasive mechanical ventilation use before intubation was independently associated with reduced risk for ICU mortality (0.34 (0.14–0.84), P  = 0.020).
Conclusions:   In patients with severe acute exacerbation of COPD requiring intubation and mechanical ventilation, logistic organ dysfunction score, rapidly fatal underlying disease and procalcitonin are independently associated with increased risk for ICU mortality. Non-invasive mechanical ventilation use before intubation was independently associated with reduced risk for ICU mortality.     

Mechanical ventilation in children with severe asthma

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.     

Impact of ventilator-associated pneumonia on outcome in patients with COPD

PURPOSES: The aim of this study was to determine the impact of ventilator-associated pneumonia (VAP) on outcome in patients with COPD. METHODS: Prospective, observational, case-control study conducted in a 30-bed ICU during a 5-year period. All COPD patients who required intubation and mechanical ventilation (MV) for > 48 h were eligible. VAP diagnosis was based on clinical, radiographic, and quantitative microbiologic criteria. Patients with unconfirmed VAP were excluded, as well as patients with ventilator-associated tracheobronchitis without subsequent VAP. Matching (1:1) criteria included MV duration before VAP occurrence, age +/- 5 years, simplified acute physiology score II on ICU admission +/- 5, and ICU admission category. Variables associated with ICU mortality were determined using univariate and multivariate analyses. RESULTS: A total of 1,241 patients were eligible; 181 patients (14%) were excluded, including 133 patients for VAT and 48 patients for unconfirmed VAP. VAP developed in 77 patients (6%), and all were successfully matched. Pseudomonas aeruginosa was the most frequently isolated bacteria (31%). ICU mortality rate (64% vs 28%), duration of MV (24 +/- 15 d vs 13 +/- 11 d [+/- SD]), and ICU stay (26 +/- 17 d vs 15 +/- 13 d) were significantly (< 0.001) higher in case patients than in control patients. VAP was the only variable independently associated with ICU mortality (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.6; p < 0.001). In VAP patients who received corticosteroids during their ICU stay compared with those who did not receive corticosteroids, mortality rate (50% vs 82%; OR, 1.8; 95% CI, 1.2 to 2.7; p = 0.002), duration of MV (21 +/- 14 d vs 27 +/- 16 d, p = 0.043), and ICU stay (22 +/- 16 d vs 31 +/- 18 d, p = 0.006) were significantly lower. CONCLUSION: VAP is associated with increased mortality rates and longer duration of MV and ICU stay in COPD patients.     

无创通气联合纤维支气管镜肺泡灌洗治疗在慢性阻塞性肺疾病急性加重并呼吸衰竭伴意识障碍患者中的临床应用

目的 探讨无创通气(noninvasive positive pressure ventilation,NIPPV)联合纤维支气管镜肺泡灌洗术治疗对慢性阻塞性肺疾病急性加重(acute exacerbation of chronic obstructive pulmonary disease,AECOPD)并呼吸衰竭伴意识障碍患者的临床疗效及安全性.方法 对入选的30例伴意识障碍和32例不伴有意识障碍的AECOPD并呼吸衰竭患者,均无应用机械通气治疗病史,在年龄、性别、病程、体质量指数匹配的情况下分为治疗组和对照组.两组患者均无机械通气禁忌证.在接受常规抗炎、平喘药物治疗的同时进行NIPPV治疗.治疗组采用NIPPV治疗的同时配合纤维支气管镜肺泡灌洗治疗.观察两组治疗前后昏迷指数评分、血气变化、NIPPV时间、有效率、成功率、NIPPV序贯有创通气治疗成功率、病死率.结果 治疗组30例中,经NIPPV配合纤维支气管镜肺泡灌洗治疗成功19例,成功率63.3%,对照组32例中,NIPPV成功21例,成功率65.63%,两组对比差异无统计学意义(P＞0.05);血气分析两组治疗后较治疗前均明显好转,但治疗后两组对比差异无统计学意义(P＞0.05);无创与有创通气序贯治疗治疗组6例,成功4例,对照组7例,成功5例,两组无创与有创通气序贯治疗抢救成功率分别为66.67%和71.43%(P＞0.05);治疗组死亡5例,病死率16.67%,对照组死亡4例,病死率12.5%(P＞0.05).结论 AECOPD并呼吸衰竭伴意识障碍不是NIPPV的禁忌证.NIPPV联合纤维支气管镜肺泡灌洗治疗对意识障碍的患者同样可以首选NIPPV治疗,在进行NIPPV治疗之前进行纤维支气管镜肺泡灌洗术,可以获得与神志清醒患者相似的疗效.但必须由有经验的呼吸科专业医护人员和熟练的纤维支气管镜操作者密切配合与严密监护下进行,及时对病情作出事实评价,及早采取无创与有创通气序贯治疗,以免延误病情.     

Long‐term non‐invasive ventilation to manage persistent ventilatory failure after COPD exacerbation

Background and objective: Patients with ventilatory failure at discharge from hospital following an exacerbation of COPD (ECOPD) have increased work of breathing and reduced inspiratory muscle strength compared with those with a normal arterial carbon dioxide tension (PaCO₂). They also have a significantly worse prognosis. Long‐term non‐invasive positive pressure ventilation (NIPPV) may offer a treatment strategy but benefits have not been established. Methods: We examined the outcomes of 35 patients, with a PaCO₂ >7.5 kPa and normal pH, following hospital admission with an ECOPD. Patients were initiated on long‐term NIPPV. Our aims were to establish if NIPPV was tolerated and to describe the effects on ventilatory parameters. Results: Daytime arterial blood gases and nocturnal ventilatory parameters improved significantly on NIPPV. Diurnal PaO₂, self‐ventilating, rose from (mean (SD)) 7.3 (1.8) to 8.1 (0.9) kPa (P = 0.005) and PaCO₂ fell from 8.8 (1.3) to 7.3 (0.8) kPa (P ≤ 0.001). Mean overnight oxygen saturations increased from 82% (7%) to 89% (2%) (P ≤ 0.001) and mean overnight transcutaneous carbon dioxide fell from 7.6 (1.3) to 5.6 (1.7) kPa (P ≤ 0.001). Similar changes were seen in a group of stable COPD patients, who initiated NIPPV without a preceding exacerbation, suggesting improvements were not solely due to recovery from exacerbation. Acceptance (89%) and compliance (8.4 (3.5) h/day) with domiciliary treatment were good. Median survival was 28.6 months (95% CI: 10.9–46.8). Conclusions: NIPPV was well tolerated in this group and appears to improve ventilation. Our preliminary data support further investigation of NIPPV in patients who remain hypercapnic after hospital admission with ECOPD.     

Non invasive ventilation in COPD

Non invasive ventilation refers to the technique of providing ventilatory support without a direct conduit to the airway. It is a promising new technique, which is particularly useful in patients with COPD. Patients with COPD are prone to develop acute exacerbations, which pushes them into acute respiratory failure. Under these circumstances, tracheal intubation and mechanical ventilation is associated with significant morbidity and mortality. A number of well conducted studies support the fact that non invasive positive pressure ventilation (NIPPV) in these circumstances reduces rates of intubation, mortality, complications and duration of hospital stay. The biggest advantage of these techniques is their simplicity, ease of implementation and improved patient comfort allowing them to retain important functions like speech, cough and swallowing. NIPPV should be instituted early in the course of acute respiratory failure due to COPD before irreversible fatigue sets in. The current thinking is that NIPPV rests the respiratory muscles allowing other therapies time to be effective. Facilities for NIPPV should be available in all hospitals admitting patients with respiratory failure. Patients with severe, stable COPD who are hypercapnic and are deteriorating despite maximal conventional treatment should definitely be offered a trial of NIPPV. In such patients NIPPV has been shown to improve quality of life, reverse blood gas abnormalities, improve exercise tolerance and reduce hospital admissions. Physicians must familiarize themselves with this promising new ventilatory technique.     

Shock on admission day is the best predictor of prolonged mechanical ventilation in the ICU

STUDY OBJECTIVES: To determine the incidence of prolonged mechanical ventilation (PMV), which is associated with increased health-care costs and risks of adverse events, and to identify its early predictors. DESIGN: Retrospective cohort. SETTING: A medical-surgical ICU in a university-affiliated hospital.Patients or participants: All patients admitted to the ICU over 3 years who received mechanical ventilation (MV) for > 12 h. INTERVENTIONS: None. MEASUREMENTS: PMV was defined as MV lasting > 21 days. We recorded epidemiologic data, severity scores, worst Pao(2)/fraction of inspired oxygen (Fio(2)), presence of shock on ICU admission day, cause for MV, length of MV, ICU length of stay (LOS), and hospital LOS. PMV patients were compared to patients weaned before 21 days (non-PMV group) to determine predictors of PMV. RESULTS: Of 551 hospital admissions, 319 patients (58%) required MV > 12 h. One hundred thirty patients died early and were excluded. Seventy-nine patients (14%) required PMV. The non-PMV group consisted of 110 patients. Simplified acute physiology score (SAPS) II, APACHE (acute physiology and chronic health evaluation) II, therapeutic intervention scoring system, Pao(2)/Fio(2), shock, ICU LOS, and hospital LOS differed significantly between groups. However, logistic regression identified shock on ICU admission day as the only independent predictor of PMV (odds ratio, 3.10; p = 0.001). SAPS II and Pao(2)/Fio(2) had the nearest coefficients and were used to build the predictive model. Sensitivity analysis was performed including the 130 patients who died early, and shock remained the most powerful predictor. CONCLUSIONS: PMV was a frequent event in this cohort. The presence of shock on ICU admission day was the only prognostic factor, even adjusting for severity of illness and hypoxemia.     

无创正压通气抑制慢性阻塞性肺疾病急性加重期患者吸气肌肉活动的机制

目的探讨无创正压通气（NIPPV）抑制慢性阻塞性肺疾病（COPD）急性发作期患者吸气肌肉活动的机制。方法12例COPD急性加重期患者接受感觉最舒适通气压力水平时的NIPPV,观察患者吸气肌肉用力和呼吸方式的变化。结果与自主呼吸（SB）相比,NIPPV时的潮气量（VT）显著增高（从408ml升到462ml,P〈0.05）;接受NIPPV后VT的增高很迅速,第一呼吸周期时即明显增高。SB时的跨膜压（Pdi）为14.04cmH2O,而NIPPV时为10.98cmH2O,比SB时约减少22%（P〈0.05）。NIPPV时Pdi的下降从第一个呼吸周期即开始,然后进一步迅速下降,治疗至第5个呼吸周期时与SB时相比开始有显著差异（P〈0.05）。SB时的呼吸肌做功（Wp）分别为0.47J/breath和0.95J/L;而NIPPV时分别为0.34J/breath和0.69J/L,比SB时分别减少28%和27%（P〈0.05）。NIPPV时Wp的下降也是从第一个呼吸周期即开始,然后进一步迅速下降,治疗至第5个呼吸周期时与SB时相比开始有显著差异（P〈0.05）。结论本实验证实了NIPPV治疗COPD急性加重期患者时吸气肌肉活动的非化学性抑制作用的存在;这种非化学性抑制作用的产生与NIPPV治疗的开始基本同步,能有效改善患者的呼吸肌肉疲劳。     

无创正压通气治疗稳定期慢性阻塞性肺疾病的疗效

无创正压通气(noninvasive positive pressure ventilation,NPPV)在慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)急性加重期和稳定期患者中都有广泛应用.对于急性加重期患者,NPPV可显著降低气管插管率、病死率、住重症监护病房(ICU)时间及住院时间等.对于稳定期患者,NPPV能显著改善呼吸困难症状及部分肺功能指标、提高PaO2水平、缓解呼吸肌疲劳、增强活动耐力以及改善睡眠和生活质量,但对于NPPV能否显著降低PaCO2水平,降低住院率、病死率、住ICU时间以及住院时间等,尚存在较大争议.充分了解NPPV在稳定期COPD患者中的疗效,对于提高NPPV的临床应用水平具有重要意义.     

家庭无创正压通气在重度慢性阻塞性肺疾病缓解期患者中的应用价值

目的 比较长期家庭无创正压通气与长期家庭氧疗治疗缓解期重度慢性阻塞性肺疾病患者的疗效.方法 80例重度慢性阻塞性肺疾病缓解期患者分为无创正压机械通气治疗组(32例)和对照组(48例).随访2年,比较2组患者病情恶化次数、住院时间及病死率、血气分析结果、肺功能及6分钟行走距离(6MWD)、观察治疗后患者症状(咳嗽、咯痰、...     

长期家庭无创正压通气治疗重度慢性阻塞性肺疾病疗效分析

目的 研究长期家庭无创正压通气(non-invasive positive pressure ventilation,NIPPV)在治疗重度慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)中的作用.方法 根据慢性阻塞性肺疾病诊断指南制定的标准,收集2002年6月至...     

Hospitalizations for COPD Exacerbations: Trends and Determinants of Death

Objectives: to understand epidemiological trends in severe COPD exacerbations through analyzes of hospitalizations and deaths during three consecutive years in a French administrative region area. Methods: Medico-administrative records of hospitalizations for COPD exacerbations were sorted from 2010 to 2012 using selected International Classification of Diseases (ICD10) codes. Four groups of hospitalization for COPD severe exacerbations were elicited leading to hospitalizations (general ward without respiratory failure, general ward with acute respiratory distress, ICU without mechanical ventilation, ICU with mechanical ventilation). Results: Data extraction identified 5007, 4986 and 5359 admissions related to 4136, 4155 and 4460 patients in 2010, 2011 and 2012, respectively. Marked seasonal variations were observed. Duration of stay (median (IQR), 7 (7) vs 9 (8) vs 10 (9) vs 14 (16) days, P < .001), death rates (3.6% vs 14.2% vs 14.4% vs 21.2%, P < .01), number of co-morbid conditions (median (IQR), 2 (2) vs 2 (2) vs 4 (5) vs 4 (4.5), P < .01), type of institution (64.9% in public institution vs 79.9% vs 87.8% vs 76.6%, P < .01) were significantly associated with the hospitalization group and more than 8% of admissions led to death (3% to 24%). Age, type of institution and past hospitalizations were independent risk factors for deaths. Readmissions were infrequent but mainly related to the worsening of the co-morbid conditions. Conclusion: COPD severe exacerbations are frequent and lead to an important numbers of deaths related to the severity of acute respiratory failure and the number of co-morbid conditions.     

Impact of acute respiratory failure on survival of COPD patients managed with long-term non-invasive ventilation and oxygen therapy

Our study aimed to assess the impact of acute respiratory failure (ARF) on survival of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) plus nasal intermittent positive pressure ventilation (NIPPV). Survival was analysed retrospectively in 24 patients with severe COPD initiated to NIPPV in addition to LTOT. Fourteen patients were established on NIPPV following exacerbation of acute respiratory failure which has required mechanical ventilation (group 1). Ten patients (group 2) have never been hospitalized for ARF. Comparison of clinical details at baseline, 6 months, 1, 2, and 3 years for the two groups failed to reveal any difference with the exception of prior episodes of ARF. The probability of survival at 3 years was 65% (95% confidence interval [CI] 43-86) for the overall population, 46% (95% CI 15-77) in group 1, and 74% (95% CI 42-105) in group 2. The difference between the two groups was statistically significant. We show that ARF requiring mechanical ventilation appears to be a factor that is negatively correlated with survival for patients treated by LTOT plus NIPPV. This data suggests that NIPPV should be tried before ARF arising in COPD patients who present a deterioration in chronic respiratory failure with hypercapnia.     

Efficacy of Low Molecular Weight Heparin in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Ventilatory Support

Introduction: Severe and acute exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a high mortality. Since COPD is an airway inflammatory disease, and heparin has shown anti-inflammatory effects in previous studies, we evaluated the clinical effect of low molecular weight heparin (LMWH; nadroparin) in COPD patients admitted into the hospital due to acute exacerbations. Methods: Sixty-six patients admitted to the intensive care unit (ICU) were randomly divided into control group (n = 33) and LMWH group (n = 33). The control group received conventional treatment, including oxygen therapy (non-invasive or conventional mechanical ventilation), anti-infection, atomization expectorant, spasmolysis, anti-asthmatics, and nutritional support. The LMWH group received the same treatment plus LMWH for 1 week. The levels of plasma C-reactive protein, interleukin-6, and fibrinogen were measured. The main outcomes were duration of mechanical ventilation, length of ICU stay, and hospital stay. Results: There were no significant differences between the groups with respect to demographics, severity of illness, and gas exchange variables. The levels of plasma C-reactive protein, interleukin-6, and fibrinogen were significantly decreased in the LMWH group. LMWH significantly reduced the mean duration of mechanical ventilation (6.6 days vs. 3.8 days; p < 0.01), the length of ICU stay (8.5 days vs. 5.6 days; p < 0.01) and hospital stay (14.3 days vs. 11.3 days; p < 0.01). Conclusions: The addition of LMWH to standard therapy benefits COPD patients with acute exacerbation.     

Clinical course and outcome of patients admitted to an ICU for status asthmaticus.

STUDY OBJECTIVES: To describe the prognostic factors, clinical course, and outcome of patients with status asthmaticus treated in a medical ICU (MICU). DESIGN: Analysis of prospective data. SETTING: A multidisciplinary MICU of an inner-city university hospital. PATIENTS: We collected data on 132 hospital admissions of 89 patients with status asthmaticus treated in our MICU from August 1995 through July 1998. MEASUREMENTS: APACHE (acute physiology and chronic health evaluation) II scores were among the parameters measured. RESULTS: Seventy-nine percent of the patients were female, and 67% were African American (mean +/- SD age, 42.4 +/- 15.1 years). Patients in 48 of the 132 hospital admissions (36%) required invasive mechanical ventilation; sepsis developed in patients during 17 hospital admissions (13%), nonpulmonary organ failure developed during 16 hospital admissions (12%), and ARDS developed during 2 hospital admissions (2%). Pneumothorax developed in four patients and required tube thoracostomy in all four patients. The median APACHE II score was 11. Predicted mortality and actual mortality were 6.7% and 8.3%, respectively. The two most common immediate causes of death were pneumothorax (n = 3) and nosocomial infection (n = 3). All the deaths occurred in female patients. Compared with survivors, nonsurvivors had higher APACHE II scores (median, 26 vs 15; p < 0.0001), PaCO(2) (63.8 +/- 21.3 mm Hg vs 47.8 +/- 19.1 mm Hg, p = 0.0101), and lower arterial pH (7.09 +/- 0.12 vs 7.27 +/- 0.12, p < 0.0001), respectively. Patients in 10 of 48 hospital admissions (21%) who required mechanical ventilation died. CONCLUSIONS: The hospital mortality of patients admitted to an MICU for status asthmaticus is higher than expected. Higher APACHE II score and PaCO(2) and lower arterial pH within 24 h of hospital admission are associated with increased mortality. Sepsis and nonpulmonary organ failure are more likely to develop in nonsurvivors than survivors.     

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death. DESIGN: Retrospective cohort. SETTING: Medical-surgical ICU in a university-affiliated hospital. PATIENTS: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014). CONCLUSIONS: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.