Asthma and chronic obstructive pulmonary disease in the intensive care unit

The prevalence of asthma and chronic obstructive pulmonary disease is increasing worldwide. Patients who require intensive care management for acute exacerbations of these conditions represent a particular challenge. The requirement for invasive mechanical ventilation is associated with many pitfalls, as evidenced by the higher mortality rate of patients undergoing this intervention. This article describes the initial management, as well as escalating respiratory support and advanced pharmacological therapies, and the current evidence supporting these. In particular, the concept of dynamic hyperinflation is addressed as well as ventilation strategies that should be employed to prevent the development of complications.     

Asthma and chronic obstructive pulmonary disease in the intensive care unit

There are many pitfalls in the management of patients with asthma or chronic obstructive pulmonary disease, especially when their condition becomes severe enough to warrant intensive care. Mortality in both groups remains significant. Standard principles of oxygen and drug administration and mechanical ventilation technique used for typical critically ill patients can all cause problems in this patient group. Recognition of the presence of airflow obstruction, the potential for dynamic hyperinflation and careful adherence to the principles of therapy specific to this group are required to avoid complications. This article addresses the physiological derangements in airflow obstruction, their treatment consequences and how to avoid the management pitfalls that are important contributors to the morbidity and mortality of both conditions.     

Asthma and chronic obstructive pulmonary disease in the intensive care unit

There are many pitfalls in the management of patients with asthma or chronic obstructive pulmonary disease, especially when their condition becomes severe enough to warrant intensive care unit level care. Mortality in both groups remains significant. Standard principles of oxygen and drug administration and mechanical ventilation technique used for typical critically ill patients can all cause problems. Recognition of the presence of airflow obstruction, the potential for dynamic hyperinflation and careful alteration of the principles and targets of therapy are required to avoid complications. In this article we examine the nature and scope of the challenge facing intensivists, highlighting difficulties in management and outlining specific strategies to aid in managing both conditions.     

Asthma and chronic obstructive pulmonary disease in the intensive care unit

There are many pitfalls in the management of patients with asthma or COPD especially when their condition becomes severe enough to warrant intensive care. Mortality in both groups remains significant. Standard principles of oxygen and drug administration and mechanical ventilation technique used for other critically ill patients can all cause problems in this patient group. Recognition of the presence of airflow obstruction, the potential for dynamic hyperinflation and careful adherence to the principles of therapy specific to this group are required to avoid complications. This article addresses the physiological derangements in airflow obstruction, their treatment consequences and how to avoid the management pitfalls that are important contributors to the morbidity and mortality of both conditions.     

Effect of exacerbations on quality of life in patients with chronic obstructive pulmonary disease: a 2 year follow up study

BACKGROUND: A study was undertaken to evaluate exacerbations and their impact on the health related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD). METHODS: A 2 year follow up study was performed in 336 patients with COPD of mean (SD) age 66 (8.2) years and mean (SD) forced expiratory volume in 1 second (FEV(1)) 33 (8)% predicted. Spirometric tests, questions regarding exacerbations of COPD, and HRQL measurements (St George's Respiratory Questionnaire (SGRQ) and SF-12 Health Survey) were conducted at 6 month intervals. RESULTS: A total of 1015 exacerbations were recorded, and 103 (30.7%) patients required at least one hospital admission during the study. After adjustment for baseline characteristics and season of assessment, frequent exacerbations had a negative effect on HRQL in patients with moderate COPD (FEV(1) 35-50% predicted); the change in SGRQ total score of moderate patients with > or =3 exacerbations was almost two points per year greater (worse) than those with <3 exacerbations during the follow up (p = 0.042). For patients with severe COPD (FEV(1) <35% predicted) exacerbations had no effect on HRQL. The change in SGRQ total score of patients admitted to hospital was almost 2 points per year greater (worse) than patients not admitted, but this effect failed to show statistical significance in any severity group. There was a significant and independent seasonal effect on HRQL since SGRQ total scores were, on average, 3 points better in measurements performed in spring/summer than in those measured in the winter (p<0.001). CONCLUSIONS: Frequent exacerbations significantly impair HRQL of patients with moderate COPD. A significant and independent effect of seasonality was also observed.     

B-cell Lymphoma in retrieved femoral heads: a long term follow up

Background  

A relatively high incidence of pathological conditions in retrieved femoral heads, including a group of patients having low grade B-cell lymphoma, has been described before. At short term follow up none of these patients with low-grade B-cell lymphoma showed evidence of systemic disease. However, the long term follow up of these patients is not known.     

Acute respiratory failure in a regional respiratory unit

One thousand, six hundred and sixteen patients with acute respiratory failure were managed in a regional respiratory unit. The patients are classified according to cause, the need for artificial ventilation and results.     

Domiciliary nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long term follow up and effect on survival

BACKGROUND—There is increasing interest in the useof non-invasive nocturnal intermittent positive pressure ventilation(NIPPV) in the management of patients with chronic hypercapnoeic (typeII) respiratory failure. Although this treatment enables patientsrequiring mechanical ventilatory support to be treated more readily athome, few studies have been done to demonstrate its long term benefitsin chronic obstructive pulmonary disease (COPD) and the application ofNIPPV in these circumstances remains controversial.
METHODS—Eleven patients in severe stable chronictype II respiratory failure due to COPD who were unresponsive toconventional treatments experienced symptomatic hypercapnia whenreceiving sufficient supplementary oxygen to result in an arterialoxygen saturation (SaO₂) of >90%. They wereassessed for treatment with NIPPV, and its effects were observed forover two years using arterial blood gas tensions, spirometricparameters and body mass index (BMI), survival, hospital admissions,use of general practitioner resources, and patient satisfaction.
RESULTS—Hospital admissions and GP consultationswere halved after one year compared with the year before NIPPV andthere was a sustained improvement in arterial blood gas tensions at 12 and 24 months when breathing air, despite progressive deterioration inventilatory function. BMI did not change during the period ofobservation. The median survival was 920 days, with no patient dyingwithin the first 500days.
CONCLUSIONS—Domiciliary NIPPV results inimprovements in arterial blood gas tensions which are sustained aftertwo years of treatment and reduces both hospital admissions and generalpractitioner visits by patients with severe COPD in hypercapnoeicrespiratory failure. It is well tolerated and, although there was nocontrol group, survival appears to be prolonged when these results are compared with those of the NOTT and MRC (LTOT) trials.

     

Acute renal failure in bone marrow transplant patients admitted to the intensive care unit

BACKGROUND/AIMS: Review of bone marrow transplant (BMT) cases admitted to our intensive care unit (ICU) and to compare co-morbidity and outcome of BMT patients developing or not developing acute renal failure (ARF). METHODS: A case review of BMT patients admitted to the ICU (a 16-bed medico-surgical ICU in a tertiary care teaching institution) over a 4-year period. RESULTS: Between January 1994 and December 1998, 57 among 441 BMT patients (12.9%) were admitted to the ICU, mainly for respiratory distress (58%) and hypotension (32%). Forty-two patients (73.7%) presented ARF as defined as a doubling of serum creatinine. Compared to the 15 other patients, ARF patients had a higher APACHE II score (30 +/- 8 vs. 25 +/- 7, p < 0.05). For ARF vs. non-ARF patients, there was no difference in age (43.8 +/- 10.8 vs. 44.3 +/- 11.1 years), in requirement for mechanical ventilation (76 vs. 73%) and vasopressors (69 vs. 60%), and in prevalence of graft-versus-host disease (19 vs. 13%) or neutropenia (69 vs. 67%), but the prevalence of sepsis (83 vs. 60%) and liver failure (69 vs. 40%) was higher. Maximum serum bilirubin was markedly increased in ARF compared to non-ARF patients (p < 0.005). For both subgroups, no difference in the administration of potential nephrotoxic agents was identified. Usually, ARF was considered multifactorial by clinicians, with ATN being the most frequent diagnosis (55%). Maximum serum creatinine reached a mean of 330 +/- 130 micromol/l. In 74% of cases, ARF occurred concomitantly or after admission to the ICU. Oligoanuria was present in 38%, whereas polyuria was observed in 17%. Fourteen ARF patients (33%) required dialytic support. Mortality rates were significantly different in ARF vs. non-ARF patients (88 vs. 60%, p < 0.05). Predictive factors for the development of ARF were liver failure (odds ratio (OR) 5.9), low serum albumin (OR 1.2) and APACHE II score (OR 1.1), whereas variables predictive of mortality were mechanical ventilation (OR 14.8), ARF (OR 5.8), liver failure (OR 3.7), and APACHE II score (OR 1.2). CONCLUSIONS: This study confirms that ARF in BMT patients admitted to the ICU is frequent, multifactorial, related to liver failure, and that its development has a negative impact on outcome.     

Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success.

BACKGROUND--Non-invasive mechanical ventilation is increasingly used in the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to identify simple parameters to predict the success of this technique. METHODS--Fifty nine episodes of acute respiratory failure in 47 patients with COPD treated with non-invasive mechanical ventilation were analysed, considering each one as successful (78%) or unsuccessful (22%) according to survival and to the need for endotracheal intubation. RESULTS--Pneumonia was the cause of acute respiratory failure in 38% of the unsuccessful episodes but only in 9% of the successful ones. Success with non-invasive mechanical ventilation was associated with less severely abnormal baseline clinical and functional parameters, and with less severe levels of acidosis assessed during an initial trial of non-invasive mechanical ventilation. CONCLUSIONS--The severity of the episode of acute respiratory failure as assessed by clinical and functional compromise, and the level of acidosis and hypercapnia during an initial trial of non-invasive mechanical ventilation, have an influence on the likelihood for success with non-invasive mechanical ventilation and may prove to be useful in deciding whether to continue with this treatment.     

Acute renal failure and pregnancy: a seventeen-year experience of a Tunisian intensive care unit

Abstract

Purpose: To describe the epidemiologic features of acute renal failure related to pregnancy (PRARF) and to evaluate its prognostic impact. Methods: Retrospective study conducted in a Tunisian intensive care unit over a period of 17 years (1995–2011). Women were included if they were more than 20 weeks pregnant and were admitted to the ICU during pregnancy or immediately (<7?d) post partum. PRARF was defined by a serum creatinine level >0.8?mg/dL and was classified as mild (0.9 to 1.4?mg/dL), moderate (1.5 to 2.9?mg/dL) or severe (>3?mg/dL). Results: Five hundred and fifty patients were included. Mean age was 31?±?6 years. Mean SOFA score was 4?±?3. PRARF was diagnosed in 313 patients (56.9%). ARF was mild in 215 cases (39.1%), moderate in 65 cases (11.8%) and severe in 33 cases (6%). Main causes leading to this complication were preeclampsia (66.5%) and acute hemorrhage (27.8%). Only two patients (0.4%) developed chronic renal failure and needed long-term dialysis. Patients who developed this complication had higher SOFA score (4.7?±?3.5 vs. 3.2?±?2.1; p?<?0.001). Thirty-three patients (6%) died in the ICU. The rate of ICU mortality was significantly higher in patients with PRARF (9.3 vs. 1.7%; p?<?0.001). Conclusions: PRARF is associated with higher mortality. Thus, appropriate monitoring of pregnancies is needed in order to prevent its onset by an early and prompt management of the underlying risk factors.     

Synergistic effect of acute renal failure and respiratory failure in the surgical intensive care unit

A retrospective evaluation of the effect of renal and respiratory failure on mortality in our surgical intensive care unit was undertaken. The coexistence of combined renal and respiratory failure had a synergistic adverse effect on survival. Combined pulmonary and kidney failure appeared to develop simultaneously. A subset of patients with severe prerenal azotemia but without uremia had the highest mortality. These results are not consistent with the simple combination of single systems failure but rather suggest that renal and respiratory failure are markers of a generalized underlying defect.     

Long term effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a meta-analysis

BACKGROUND—The role of inhaled corticosteroids in the long term management of chronic obstructive pulmonary disease (COPD) is still unclear. A meta-analysis of the original data sets of the randomised controlled trials published thus far was therefore performed. The main question was: "Are inhaled corticosteroids able to slow down the decline in lung function (FEV₁) in COPD?"METHODS—A Medline search of papers published between 1983 and 1996 was performed and three studies were selected, two of which were published in full and one in abstract form. Patients with "asthmatic features" were excluded from the original data. Ninety five of the original 140 patients treated with inhaled corticosteroids (81 with 1500 µg beclomethasone daily, six with 1600 µg budesonide daily, and eight with 800 µg beclomethasone daily) and 88 patients treated with placebo (of the initial 144 patients) were included in the analysis. The effect on FEV₁ was assessed by a multiple repeated measurement technique in which points of time in the study and treatment effects (inhaled corticosteroids compared with placebo) were investigated.RESULTS—No baseline differences were observed (mean age 61 years, mean FEV₁ 45% predicted). The estimated two year difference in prebronchodilator FEV₁ was +0.034 l/year (95% confidence interval (CI) 0.005 to 0.063) in the inhaled corticosteroid group compared with placebo. The postbronchodilator FEV₁ showed a difference of +0.039 l/year (95% CI -0.006 to 0.084). No beneficial effect was observed on the exacerbation rate. Worsening of the disease was the reason for drop out in four patients in the treatment group compared with nine in the placebo group. In the treatment group six of the 95 subjects dropped out because of an adverse effect which may have been related to the treatment compared with two of the 88 patients in the placebo group.CONCLUSIONS—This meta-analysis in patients with clearly defined moderately severe COPD showed a beneficial course of FEV₁ during two years of treatment with relatively high daily dosages of inhaled corticosteroids.     

Biliary-intestinal bypass in the treatment of obesity: long term follow up.

OBJECTIVE: To evaluate the long term outcome after biliary-intestinal bypass for morbid obesity. DESIGN: Retrospective study. SETTING: County hospital, Sweden. SUBJECTS: 120 consecutive patients operated on between 1977 and 1990. INTERVENTIONS: A variation of jejunoileal bypass in which the excluded bowel was anastomosed to the gallbladder. MAIN OUTCOME MEASURES: Weight, concentrations of blood lipids and glucose in blood, results of liver function tests, reversal rates, and complications. RESULTS: The mean body mass index was reduced by 39% (from 42 kg/m2 to 26 kg/m2), serum cholesterol and triglyceride concentrations by more than 30%, and fasting blood glucose concentrations by 1 1%. There were no cases of irreversible hepatic failure, diabetes, deaths related to the operation, or progressive renal failure. The incidence of renal calculi increased by a ratio 2.3. The reversal rate/year was 2% (n = 20). CONCLUSION: We conclude that biliary-intestinal bypass may be used to treat cases of obesity associated with seriously high blood lipid concentrations and where gastric restrictive operations are less suitable.     

Acute respiratory distress syndrome in the trauma intensive care unit: Morbid but not mortal

HYPOTHESIS: The diagnosis of acute respiratory distress syndrome (ARDS) carries significant additional morbidity and mortality among critically injured patients. DESIGN: Retrospective case-control study using a prospectively maintained ARDS database. SETTING: Surgical intensive care unit (ICU) in an academic county hospital. PATIENTS: All trauma patients admitted to the ICU from January 1, 2000, to December 31, 2003, who developed ARDS as defined by (1) acute onset, (2) a partial pressure of arterial oxygen-fraction of inspired oxygen ratio of 200 or less, (3) bilateral pulmonary infiltrates on chest radiographs, and (4) absence of left-sided heart failure. Each patient with ARDS was matched with 2 control patients without ARDS on the basis of sex, age (+/-5 years), mechanism of injury (blunt or penetrating), Injury Severity Score (+/-3), and chest Abbreviated Injury Score (+/-1). MAIN OUTCOME MEASURES: Mortality, hospital charges, hospital and ICU lengths of stay, and complications (defined as pneumonia, deep venous thrombosis, pulmonary embolism, acute renal failure, and disseminated intravascular coagulopathy). RESULTS: Of 2042 trauma ICU admissions, 216 patients (10.6%) met criteria for ARDS. We identified 432 similarly injured control patients. Compared with controls, trauma patients with ARDS had more complications (43.1% vs 9.5%), longer hospital (32.2 vs 17.9 days) and ICU (22.1 vs 8.4 days) lengths of stay, and higher hospital charges (267,037 dollars vs 136,680 dollars) (P < .01 for all), but mortality was similar (27.8% vs 25.0%, P = .48). CONCLUSION: Although ARDS is associated with increased morbidity, hospital and ICU length of stay, and costs, it does not increase overall mortality among critically ill trauma patients.     

The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit

Most deaths from acute asthma occur outside hospital, but the at-risk patient may be recognised on the basis of prior ICU admission and asthma medication history. Patients who fail to improve significantly in the emergency department should be admitted to an HDU or ICU for observation, monitoring, and treatment. Hypoxia, dehydration, acidosis, and hypokalaemia render the severe acute asthmatic patient vulnerable to cardiac dysrrhythmia and cardiorespiratory arrest. Mechanical ventilation may be required for a small proportion of patients for whom it may be life saving. Aggressive bronchodilator (continuous nebulised beta agonist) and anti-inflammatory therapy must continue throughout the period of mechanical ventilation. Recognised complications of mechanical ventilation include hypotension, barotrauma, and nosocomial pneumonia. Low ventilator respiratory rates, long expiratory times, and small tidal volumes help to prevent hyperinflation. Volatile anaesthetic agents may produce bronchodilation in patients resistant to beta agonists. Fatalities in acute asthmatics admitted to HDU/ICU are rare.     

Acute renal failure needing dialysis in the intensive care unit and prognostic scores

BACKGROUND: Generic prognostic scores used in acute renal failure (ARF) give imprecise results; disease-specific indices applied to distinct populations or intensive care practices becomes inaccurate. The current study evaluates the adequacy of prognostic scores, in patients with severe ARF needing dialysis. METHODS: Known generic (APACHE II) and disease-specific (ATN-ISS) indices were applied to a cohort (n = 280) with ARF needing dialysis, under intensive care. Possible risk factors as causal factors, organ dysfunctions and clinical variables were examined, and a local index assembled by multivariate logistic regression analysis. Area under the receiver operating characteristics (ROC) curves evaluated the indices discriminating capacity. Goodness-of-fit testing and linear regression analysis appraised calibration. Validation was accomplished by the bootstrapping technique. The end-point was hospital mortality. RESULTS: Overall mortality was 85%. Female gender < 44 years (OR: 0.29; 95% CI: 0.10-0.84), liver/obstructive biliary disease (OR: 6.03; 95% CI: 1.65-22.08), being conscious (OR: 0.49; 95% CI: 0.21-1.14), use of vasoactive drug (OR: 3.13; 95% CI: 1.25-7.83), respiratory dysfunction (OR: 5.20; 95% CI: 1.25-7.83) or sepsis (OR: 2.62; 95% CI: 1.14-6.02) were associated with outcome. Areas under the ROC curve of 0.815, 0.652 and 0.814; Goodness-of-fit test P = 0.593, P < 0.001 and P = 0.002; and linear regression R2 = 0.973, R2 = 0.526 and R2 = 0.919 for the local index, APACHE II and ATN-ISS, respectively, indicate better performance by the local index. The local index median area under the ROC curve, by bootstrapping, was 0.820 (95% CI: 0.741-0.907). CONCLUSIONS: APACHE II score was inaccurate, and ATN-ISS poorly calibrated. When mortality or intensive care practices significantly deviate, local scores may better evaluate prognosis in severe ARF.     

Acute renal failure in an intensive care unit: incidence, prediction and outcome

A review of the case notes of 475 patients with no history of renal disorder admitted to an intensive care unit, showed that 23% (109) developed acute renal failure. This complication occurred more commonly in patients with major burns (75%), and following surgery to the abdominal aorta (38%), but less commonly after self-poisoning episodes (5%).
Scores were provided from stepwise multiple regression analysis which were derived from the diagnostic group, the presence of sepsis, the presence of systolic hypotension and age, and correctly predicted development of acute renal failure in 79% of the cases studied. Attempted prophylaxis appears to have little effect on the incidence of acute renal failure whilst dialysis reduced the mortality from 95% to 72%. Use of the scoring system to allow earlier diagnosis and treatment of acute renal failure could reduce the present mortality by 43%.     

Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome

BACKGROUND: Non-invasive ventilation (NIV) reduces the need for intubation and the mortality associated with an exacerbation of chronic obstructive pulmonary disease (COPD). This study aimed to identify factors that could be used to stratify patients according to their risk of requiring invasive mechanical ventilation. The second aim was to determine the long term survival of patients treated with and without NIV. METHODS: In this prospective multicentre randomised controlled trial 118 patients were allocated to standard treatment and 118 to NIV between November 1996 and September 1998. Arterial blood gas tensions and respiratory rate were recorded at enrolment and after 1 and 4 hours. Prognostic factors were identified using logistic regression analysis. All patients were followed until death or 1 January 1999. RESULTS: At enrolment the H(+) concentration (OR 1.22 per nmol/l, 95% CI 1.09 to 1.37, p<0.01) and PaCO2 (OR 1.14 per kPa, 95% CI 1.14 to 1.81, p<0.01) were associated with treatment failure. Allocation to NIV was protective (OR 0.39, 95% CI 0.19 to 0.80). After 4 hours of treatment improvement in acidosis (OR 0.89 per nmol/l, 95% CI 0.82 to 0.97, p<0.01) and fall in respiratory rate (OR 0.92 per breaths/min, 95% CI 0.84 to 0.99, p=0.04) were associated with success. Median length of survival was 16.8 months in those treated with NIV and 13.4 months in those receiving standard treatment (p=0.12). The trend in improved survival was attributable to prevention of death during the index admission. CONCLUSION: Initial pH and hypercapnia can be used to stratify groups of patients according to their risk of needing intubation. NIV reduces this risk and progress should be monitored using change in respiratory rate and pH. The long term survival after NIV is sufficiently good to render treatment appropriate.