Ultrasonographic bedside evaluation of maxillary sinus disease in mechanically ventilated patients

Objective: Evaluate A-mode ultrasonographic examination of maxillary sinus disease in mechanically ventilated, critically ill patients using sinoscopy as criterion standard. Design: Prospective case series. Setting: The intensive care units of a tertiary care hospital. Patients: 25 mechanically ventilated, critically ill patients with nasotracheal intubation or a tracheotomy were followed up by ultrasonographic examination of the maxillary sinuses in supine and semirecumbent positions. Infectious sinusitis was suspected in 15 patients, who were bilaterally sinoscoped combined with sampling for bacterial culture. Results: The frequency of oedema and/or secretions was high: 29 antra of 30 examined. Only 2 of 30 antra showed bacterial infection. Ultrasonographic examinations were sensitive to general pathological changes but less accurate in specific diagnostics such as the presence of secretions (sensitivity for fluid 75 %, oedema 81 %). The sensitivity of ultrasonographic diagnosis improved when the examination was made in the semirecumbent position (sensitivity for fluid 91 %, oedema 81 %). Conclusions: A-mode ultrasonography is a useful method for daily use, being easy to perform and without discomfort to the patient. It is fast and gives an immediate diagnosis. In intensive care unit patients, it should be the method of choice for day-to-day studies of effects and changes in the upper airways. For the differential diagnosis of oedema and/or secretions, it is not reliable enough to be used as the sole diagnostic method. A complementary investigation, such as computed tomography or sinoscopy, which also provides the opportunity to take samples, is needed for diagnostic confidence. Received: 28 March 1996 Accepted: 6 December 1996     

Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit-patients: a systematic review

ABSTRACT: INTRODUCTION: Manual hyperinflation (MH), a frequently applied maneuver in critically ill intubated and mechanically ventilated patients, is suggested to mimic a cough so that airway secretions are mobilized towards the larger airways where they can easily be removed. As such, MH could prevent plugging of the airways. METHOD: We performed a search in the databases of Medline, Embase and the Cochrane Library from January 1990 to April 2012. We systematically reviewed the literature on evidence for postulated benefits and risks of MH in critically ill intubated and mechanically ventilated patients. RESULTS: The search identified 50 articles, of which 19 were considered relevant. We included 13 interventional studies and 6 observational studies. The number of studies evaluating physiological effects of MH is limited. Trials differed too much to permit meta-analysis. It is uncertain whether MH was applied similarly in the retrieved studies. Finally, most studies are underpowered to show clinical benefit of MH. Use of MH is associated with short-term improvements in lung compliance, oxygenation and secretion clearance, without changes in outcomes. MH has been reported to be associated with short-term and probably clinically insignificant side-effects, including decreases in cardiac output, alterations of heart rates and increased central venous pressures. CONCLUSIONS: Studies have failed to show MH benefits critically ill intubated and mechanically ventilated patients. MH is infrequently associated with short-term side-effects.     

Prevention of nosocomial maxillary sinusitis in the ICU: the effects of topically applied α-adrenergic agonists and corticosteroids

Objective We investigated the efficacy of locally applied nasal decongestant agents and corticosteroids for preventing nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma. Design and setting A prospective, open-label randomized study in two intensive care units (ICUs). Patients 79 consecutive multiple trauma patients admitted to the ICU who were expected to be mechanically ventilated for more than 3 days. Interventions Patients were randomly assigned to receive either a combination of a locally applied nasal decongestant agents: 2 drops twice/day of xylometazoline nasal solution 0.1% and 100 μg budesonide (NDCA group, n = 39) or placebo (control group, n = 40). Measurements For the diagnosis of radiological maxillary sinusitis patients underwent paranasal computed tomography within 48 h of admission and thereafter every 4–7 days. Infectious maxillary sinusitis was diagnosed by microbiological analysis of fluid aspirated after transnasal puncture of maxillary sinuses. Results Radiological maxillary sinusitis was detected in 54% of patients in the NDCA group (n = 21) but in 82% of controls (p < 0.01), and infectious maxillary sinusitis in 8% of the NDCA group (n = 3) but in 20% of controls (n = 8; p = 0.11). The most common pathogen micro-organisms identified from maxillary aspirates were Acinetobacter (32%) followed by anaerobes (21%). Conclusion Our results indicate that the combination of locally applied xylometazoline hydrochloride and budesonide reduces the incidence of radiological maxillary sinusitis and may reduce also that of nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma. Supported by a grant from the Society for Pulmonary and Critical Care Research of East Macedonia and Thrace     

功能残气量在重症患者中的应用进展

功能残气量（FRC）是平静呼气末肺内残留的气体量,具有重要的生理功能。在需要机械通气的重症患者中呼气结束时的肺容积被称为呼气末肺容积。目前临床上有多种检测和监测FRC的方法,包括CT测量法、氦气稀释法、氮气冲洗法、电阻抗断层成像技术等方法,其中氮气冲洗法中的氮气洗入/洗出技术更适合在重症患者中开展。FRC可以作为评估机械通气患者肺部疾病病情并指导个性化的保护性机械通气策略的方法,来降低呼吸机相关性肺损伤（VILI）。FRC在机械通气患者中的临床应用越来越受到重视,在病情评估、ARDS患者中的肺保护通气设置和麻醉时肺部情况监测等方面具有重要临床意义。本文对FRC的病理生理功能、检测方法及在重症患者中的应用进行综述。     

Evaluation by polymerase chain reaction of cytomegalovirus reactivation in intensive care patients under mechanical ventilation

Objective The study was undertaken to determine if critically ill patients under mechanical ventilation could reactivate latent cytomegalovirus (CMV) in either lung or blood.Design Prospective study in critically ill patients.Setting The study was performed in a multidisciplinary intensive care unit in a university hospital.Patients 23 non-immunocompromised, mechanically ventilated patients who were anti-CMV immunoglobulin G-positive. Ten immunocompromised patients with active CMV infection and 16 asymptomatic CMV seropositive non-immunocompromised patients constituted the positive and negative control groups.Measurements and results The presence of CMV in blood and bronchoalveolar lavage (BAL) was evaluated by both viral cultures and polymerase chain reaction (PCR). Thirty-seven blood and 22 BAL samples were investigated. Sequential samples were evaluated in 8 patients. For PCR, a 290 bp fragment in the first exon of the immediate early 1 gene was amplified. In order to exclude inhibitors of PCR amplification, a 268 bp fragment of the -globin gene was concurrently amplified in all samples. Viral cultures of blood and BAL were negative in all 23 non-immunocompromised, mechanically ventilated patients. Moreover, no CMV DNA could be amplified in blood or BAL samples, whereas a -globin amplification was observed in all samples.Conclusion In a series of 23 critically ill patients under mechanical ventilation who were seropositive for CMV, no reactivation of CMV in blood or lung was demonstrated.     

Association of prophylactic synbiotics with reduction in diarrhea and pneumonia in mechanically ventilated critically ill patients: A propensity score analysis

Introduction

The preventive association of synbiotics therapy has not been thoroughly clarified in mechanically ventilated patients. The purpose of this study was to evaluate whether synbiotics therapy has preventive association against septic complications in ventilated critically ill patients.

B-mode ultrasound in the diagnosis of maxillary sinusitis in intensive care unit

Radiological maxillary sinusitis (RMS) is not an easily diagnosed in Intensive Care Unit (ICU). B-mode ultrasound of paranasal sinuses, validated for the ambulatory patients, was evaluated in a prospective study. One hundred fifty three ultrasound examinations were performed on 30 critically ill patients and compared to CT scan or radiography (Blondeau's view). Two levels of positive echographia are described: positive echographia corresponding with a moderate lesion, cupuliform echographia when the lesion is more significant. Its good predictive negative value when the echographia is negative and its predictive positive value of 100 % when the echographia is cupuliform allow to recommend B-mode ultrasound as the best investigation for the diagnosis of maxillary sinusitis in a ICU. Diagnostic ultrasound represents a rapid, painless, innocuous and easily reproducible means of monitoring. Received:21 May 1997 Accepted: 4 September 1997     

Paralysis has no effect on chest wall and respiratory system mechanics of mechanically ventilated,sedated patients

Objective To evaluate the separate effects of sedation and paralysis on chest wall and respiratory system mechanics of mechanically ventilated, critically ill patients.Setting: ICU of the University La Sapienza Hospital, Rome.Patients and participants 13 critically ill patients were enrolled in this study. All were affected by disease involving both lungs and chest wall mechanics (ARDS in 4 patients, closed chest trauma without flail chest in 4 patients, cardiogenic pulmonary oedema with fluidic overload in 5 patients).Measurements and results Respiratory system and chest wall mechanics were evaluated during constant flow controlled mechanical ventilation in basal conditions (i. e. with the patients under apnoic sedation) and after paralysis with pancuronium bromide. In details, we simultaneously recorded airflow, tracheal pressure, esophageal pressure and tidal volume; with the end-inspiratory and end-expiratory airway occlusion technique we could evaluate respiratory system and chest wall elastance and resistances. Lung mechanics was evaluated by subtracting chest wall from respiratory system data. All data obtained in basal conditions (with the patients sedated with thiopental or propofol) and after muscle paralysis were compared using the Student'st test for paired data. The administration of pancuronium bromide to sedated patients induced a complete muscle paralysis without producing significant modification both to the viscoelastic and to the resistive parameters of chest wall and respiratory system.Conclusions This study demonstrates the lack of additive effects of muscle paralysis in mechanically ventilated, sedated patients. Also in view of the possible side effects of muscle paralysis, our results question the usefulness of generalyzed administration of neuromuscular blocking drugs in mechanically ventilated patients.     

Aerosol therapy in intensive and intermediate care units: prospective observation of 2808 critically ill patients

Purpose

Unlike in the outpatient setting, delivery of aerosols to critically ill patients may be considered complex, particularly in ventilated patients, and benefits remain to be proven. Many factors influence aerosol delivery and recommendations exist, but little is known about knowledge translation into clinical practice.

Methods

Two-week cross-sectional study to assess the prevalence of aerosol therapy in 81 intensive and intermediate care units in 22 countries. All aerosols delivered to patients breathing spontaneously, ventilated invasively or noninvasively (NIV) were recorded, and drugs, devices, ventilator settings, circuit set-up, humidification and side effects were noted.

Results

A total of 9714 aerosols were administered to 678 of the 2808 admitted patients (24 %, CI₉₅ 22–26 %), whereas only 271 patients (10 %) were taking inhaled medication before admission. There were large variations among centers, from 0 to 57 %. Among intubated patients 22 % (n = 262) received aerosols, and 50 % (n = 149) of patients undergoing NIV, predominantly (75 %) inbetween NIV sessions. Bronchodilators (n = 7960) and corticosteroids (n = 1233) were the most frequently delivered drugs (88 % overall), predominantly but not exclusively (49 %) administered to patients with chronic airway disease. An anti-infectious drug was aerosolized 509 times (5 % of all aerosols) for nosocomial infections. Jet-nebulizers were the most frequently used device (56 %), followed by metered dose inhalers (23 %). Only 106 (<1 %) mild side effects were observed, despite frequent suboptimal set-ups such as an external gas supply of jet nebulizers for intubated patients.

Conclusions

Aerosol therapy concerns every fourth critically ill patient and one-fifth of ventilated patients.

     

Erythropoietin response in critically ill mechanically ventilated patients: a prospective observational study

Introduction

Anemia is a common problem in critically ill patients. The etiology of anemia of critical illness is often determined to be multifactorial in the clinical setting, but the pathophysiology remains to be elucidated. Erythropoietin (EPO) is an endogenous glycoprotein hormone that serves as the primary stimulus for erythropoiesis. Recent evidence has demonstrated a blunted EPO response as a factor contributing to anemia of critical illness in specific subsets of patients. Critically ill patients requiring mechanical ventilation who exhibit anemia have not been the subject of previous studies. Our goal was to evaluate the erythropoietic response to anemia in the critically ill mechanically ventilated patient.

Methods

A prospective observational study was undertaken in the medical intensive care unit of a tertiary care, military hospital. Twenty patients admitted to the medical intensive care unit requiring mechanical ventilation for at least 72 hours were enrolled as study patients. EPO levels and complete blood count were measured 72 hours after admission and initiation of mechanical ventilation. Admission clinical and demographic data were recorded, and patients were followed for the duration of mechanical ventilation. Twenty patients diagnosed with iron deficiency anemia in the outpatient setting were enrolled as a control population. Control patients had baseline complete blood count and iron panel recorded by primary care physicians. EPO levels were measured at the time of enrollment in conjunction with complete blood count.

Results

The mean EPO level for the control population was 60.9 mU/ml. The mean EPO level in the mechanically ventilated patient group was 28.7 mU/ml, which was significantly less than in the control group (P = 0.035). The mean hemoglobin value was not significantly different between groups (10.6 g/dl in mechanically ventilated patients versus 10.2 g/dl in control patients; P > 0.05).

Conclusion

Mechanically ventilated patients demonstrate a blunted EPO response to anemia. Further study of therapies directed at treating anemia of critical illness and evaluating its potential impact on mechanical ventilation outcomes and mortality is warranted.

     

Daytime variations in energy expenditure in critically ill patients

Although a diurnal pattern in energy expenditure (EE) exists in normal individuals, it is unknown if a pattern is present in mechanically ventilated, critically ill patients. Oxygen consumption and carbon dioxide production were measured to indirectly determine EE in 12 critically ill patients. Resting EE measurements were performed at 7 am, 12 noon, and 5 pm. Average measured resting EE exceeded the predicted normal EE by 42% ± 11% (mean ± SD). Resting EE was not significantly different at the three time intervals; at 7 am, 12 noon, and 5 pm, resting EE was 2,006 ± 567, 2,032 ± 537, and 2,043 ± 531 kcal/d, respectively. However, for individual patients, EE varied up to 15% between the three measurements. Our findings do not support the presence of a diurnal pattern in EE in mechanically ventilated, critically ill patients, but emphasize the variation in measured EE in individual patients.     

Impaired gastric emptying in mechanically ventilated,critically ill patients

Objective To measure gastric emptying in critically ill patients using an acetaminophen absorption model and determine which variables are associated with impaired gastric emptying.Design A prospective, cohort study.Setting A medical/surgical ICU at a tertiary care hospital: Hamilton General Hospital, Hamilton, Ontario.Patients and participants We recruited 72 mechanically ventilated patients expected to remain in the ICU for more than 48h. Our results were compared to those in healthy volunteers.Intervention Within 48 h of admission to the ICU, 1.6 g acetaminophen suspension were administered via a nasogastric tube into the stomach. Blood samples were drawn at=0, 30, 60, 90, and 120 min for measurement of plasma acetaminophen levels determined by the enzymatic degradation method.Measurements and results Maximal concentration of acetaminophen was 94.1 (75.3) mol/l compared to 208.4 (33.1) mol/l in a control population (p<0.0001). The time to reach the maximal concentration was 105 min (60–180) compared to 30 min (15–90) in controls (p<0.0001). The area under the time-acetaminophen concentration curvet=120 was 9301 (7343) mol/min per 1 compared to 11644 (1336) mol/min per 1 in the controls (p=0.28). The variables associated with delayed gastric emptying were age, sex and use of opioids for analgesia and sedation.Conclusions Gastric emptying is delayed in critically ill patients. The important consequences of this phenomenon include intolerance to enteral nutrition and gastric colonization. Strategies to minimize the use of narcotics may improve gastric emptying. Studies to examine the effect of gastrointestinal prokinetic agents on gastric emptying are needed.     

Use of the probiotic <Emphasis Type="Italic">Lactobacillus plantarum</Emphasis> 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study

Introduction  

Ventilator-associated pneumonia (VAP) is usually caused by aspiration of pathogenic bacteria from the oropharynx. Oral decontamination with antiseptics, such as chlorhexidine (CHX) or antibiotics, has been used as prophylaxis against this complication. We hypothesised that the probiotic bacteria Lactobacillus plantarum 299 (Lp299) would be as efficient as CHX in reducing the pathogenic bacterial load in the oropharynx of tracheally intubated, mechanically ventilated, critically ill patients.     

Nursing interventions to prevent corneal injury in critically ill sedated and mechanically ventilated patients: A systematic review of interventions

ObjectiveTo identify the effectiveness of interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients.Research methodologyA systematic review of intervention studies was conducted in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus and Web of Science, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study selection and data extraction were performed by two independent reviewers. Quality assessment of the randomized and non-randomized studies was performed using the Risk of Bias (RoB 2.0) and ROBINS-I Cochrane tools, respectively, and the Newcastle-Ottawa Scale for cohort studies. The certainty of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.Results15 studies were included. Meta-analysis showed that the risk of corneal injury in the lubricants group was 66% lower (RR = 0.34; 95 %CI: 0.13–0.92) than in the eye-taping group. The risk of corneal injury in the polyethylene chamber was 68% lower than in the eye ointment group (RR = 0.32; 95 %CI 0.07–1.44). The risk of bias was low in most of the studies included and the certainty of the evidence was evaluated.ConclusionsThe most effective interventions to prevent corneal injury in critically ill sedated mechanically ventilated, who have compromised blinking and eyelid closing mechanisms, are ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber.Implications for clinical practiceCritically ill, sedated, and mechanically ventilated patients who have compromised blinking and eyelid closing mechanisms must receive interventions to prevent corneal injury. Ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber were the most effective interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients. A polyethylene chamber must be made commercially available for critically ill, sedated, and mechanically ventilated patients.     

Twenty-four hour energy expenditure in critically ill patients

Resting energy expenditure (EE) is often used as the basis of nutritional support for critically ill patients but whether resting EE is representative of total daily EE is not known. EE was measured for 24 h in ten mechanically ventilated, critically ill patients (average Acute Physiology and Chronic Health Evaluation II score 23) to determine EE, resting EE, and the energy expended during various ICU activities. Although activities, such as weighing the patient on a sling-type bed scale, repositioning, and chest physiotherapy resulted in dramatic EE increases above resting levels (36%, 31%, and 20%, respectively), the actual contribution of these activities to total EE was small (1.1%, 2.1%, and 3.6%, respectively). The mean measured resting EE was 47.3 +/- 22.3% above mean predicted EE based on the Harris and Benedict equation, and the mean total 24-h EE was 6.9 +/- 2.6(SD)% above the mean measured resting EE. In this group of mechanically ventilated, critically ill patients, an activity factor of no greater than 10% above resting EE is appropriate.     

Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis

Introduction  

Nosocomial pneumonia is the most important infectious complication in patients admitted to intensive care units. Kinetic bed therapy may reduce the incidence of nosocomial pneumonia in mechanically ventilated patients. The objective of this study was to investigate whether kinetic bed therapy reduces the incidence of nosocomial pneumonia and improves outcomes in critically ill mechanically ventilated patients.     

Effects of propofol on sleep quality in mechanically ventilated critically ill patients: a physiological study

Purpose

To access the effect of propofol administration on sleep quality in critically ill patients ventilated on assisted modes.

Methods

This was a randomized crossover physiological study conducted in an adult ICU at a tertiary hospital. Two nights’ polysomnography was performed in mechanically ventilated critically ill patients with and without propofol infusion, while respiratory variables were continuously recorded. Arterial blood gasses were measured in the beginning and at the end of the study. The rate of propofol infusion was adjusted to maintain a sedation level of 3 on the Ramsay scale. Sleep architecture was analyzed manually using predetermined criteria. Patient–ventilator asynchrony was evaluated breath by breath using the flow–time and airway pressure–time waveforms.

Results

Twelve patients were studied. Respiratory variables, patient–ventilator asynchrony, and arterial blood gasses did not differ between experimental conditions. With or without propofol all patients demonstrated abnormal sleep architecture, expressed by lack of sequential progression through sleep stages and their abnormal distribution. Sleep efficiency, sleep fragmentation, and sleep stage distribution (1, 2, and slow wave) did not differ with or without propofol. Compared to without propofol, both the number of patients exhibiting REM sleep (p?=?0.02) and the percentage of REM sleep (p?=?0.04) decreased significantly with propofol.

Conclusions

In critically ill patients ventilated on assisted modes, propofol administration to achieve the recommended level of sedation suppresses the REM sleep stage and further worsens the poor sleep quality of these patients.     

Effect of neuromuscular blockade on oxygen consumption and energy expenditure in sedated, mechanically ventilated children

OBJECTIVE: To quantify the effects of neuromuscular blockade (NMB) on energy expenditure for intubated, mechanically ventilated, critically ill children. DESIGN: A prospective, unblinded clinical study. Each subject was studied twice, before and after establishment of NMB. SETTING: A tertiary care pediatric intensive care unit. PATIENTS: Critically ill children undergoing mechanical ventilation and receiving ongoing sedation were eligible, if they had a cuffed endotracheal tube and were physiologically stable. INTERVENTIONS: A total of 20 children (age, 1 to 15 yrs) were studied in an unblinded, crossover fashion. All were mechanically ventilated via a cuffed endotracheal tube, with ventilator rate and tidal volume adequate to provide complete ventilation, and F(IO2) <0.6. Absence of gas leak around the endotracheal tube was assured, and all patients were sedated using continuous infusions of midazolam and/or fentanyl; no changes in ventilator settings, nutritional input, or inotropic drug dose were permitted during the study period. Each patient underwent indirect calorimetry immediately before establishment of NMB. NMB was then induced, and indirect calorimetry was repeated. Complete blockade was verified using a peripheral nerve stimulator. In each case, the two sets of measurements were completed within a 1-hr period. MEASUREMENTS AND MAIN RESULTS: Data analyzed included identifying and diagnostic information, oxygen consumption, and carbon dioxide production. Energy expenditure was calculated using standard formulas. Oxygen consumption and energy expenditure values obtained before and after the establishment of NMB were compared by using paired Student's t-test. NMB reduced oxygen consumption from 6.54+/-0.49 mL/kg/min to 5.90+/-0.40 ml/kg/min, and energy expenditure was reduced from 46.5+/-3.7 kcal/kg/24 hrs to 41.0+/-2.8 kcal/kg/24 hrs (p < .001 in each case). The reduction in oxygen consumption was 8.7+/-1.7%, and that in energy expenditure 10.3+/-1.8%, of pre-NMB values, respectively. CONCLUSION: NMB significantly reduces oxygen consumption and energy expenditure in critically ill children who are sedated and mechanically ventilated; the degree of reduction is small.     

Positive and negative effects of mechanical ventilation on sleep in the ICU: a review with clinical recommendations

Purpose

Sleep is an essential physiologic process that helps to restore normal body homeostasis. Sleep disturbances have been shown to be associated with poor clinical outcomes, such as a greater risk of cardiovascular disease and increasing mortality. Critically ill patients, particularly those receiving mechanical ventilation, may be more susceptible to sleep disruption.

Methods and Results

Mechanical ventilation is an important factor influencing sleep in critically ill patients as it may have positive or negative effects, depending on patient population, mode, and specific settings. Other causes of sleep disruption include the acute illness itself, the daily routine care, and the effects of medications. Improving sleep in patients admitted to an intensive care unit has the potential to improve both short- and long-term clinical outcomes. In this article we review the specific aspects of sleep in critically ill mechanically ventilated patients, including abnormal sleep patterns and loss of circadian rhythm, as well as the effects of mechanical ventilation and intravenous sedatives on sleep quality and quantity.

Conclusions

We provide recommendations for clinicians regarding optimal ventilatory settings and discuss fields for future research.