真菌性呼吸机相关性肺炎危险因素分析

目的探讨机械通气患者真菌性呼吸机相关性肺炎(FVAP)的易患因素和病原学特点。方法将2005年1月-2009年10月收治的84例呼吸机相关性肺炎(VAP)患者分为FVAP组和非真菌性呼吸机相关性肺炎(NFVAP)组,比较两组真菌感染的易患因素;分析FVAP组病原菌的分布特点。结果 FVAP组全身应用激素、联合应用抗菌药物和机械通气时间较长(大于7天)的比例显著大于NFVAP组(p0.05);FVAP组痰标本共培养出真菌30例,其中假丝酵母菌属24株,占80%(白色假丝酵母菌14株,占46.6%;热带假丝酵母菌6株,占20.0%;克柔假丝酵母和近平滑假丝酵母菌各2株,各占6.7%);烟曲霉菌6株,占20.0%。结论为避免FVAP的发生应严格掌握全身应用激素适应症和剂量,避免联合抗菌药物的应用和尽可能缩短机械通气时间;明确感染真菌菌属及其敏感药物,对临床选择有效的抗真菌治疗具有指导作用。     

呼吸机相关性肺炎危险因素病例对照分析与护理策略

目的分析呼吸机相关性肺炎(ventilator associated pneumonia,VAP)的危险因素,为临床预防治疗VAP提供参考依据。方法回顾2010年1月～2011年12月我院864例机械通气时间≥48 h患者的相关住院资料,以同期726例非VAP为对照组,分析VAP发病的危险因素。结果 VAP发病率为15.9%。单因素分析发现,机械通气>5 d、侵入性操作、留置胃管、APACHEⅡ评分>15分、意识障碍、口腔护理、抬高床头、每日唤醒排痰与发生VAP有关(P<0.01或P<0.05);Logistic回归分析发现APACHEⅡ评分>15分、意识障碍、留置胃管、机械通气>5 d和神经损伤为VAP发生的独立危险因素,而口腔护理、患者抬高30°、每日唤醒排痰是VAP的保护性因素。结论机械通气具有较高的VAP发病率,合理的护理策略与尽早撤机缩短机械通气有利于防止VAP的发生。     

大潮气量通气治疗围手术期呼吸机相关性肺炎

目的评价大潮气量（VT）通气对围手术期呼吸机相关性肺炎（VAP）的治疗价值。方法选择心肺功能较好、一般情况稳定的手术后VAP患者26例,随机分为对照组和治疗组,观察5d。对照组维持原常规或小VT及其他通气参数不变,治疗组改用大VT、慢呼吸频率（RR）通气。结果 1h后,治疗组VT从（7.8±0.6）ml/kg增至（13.5±1.1）ml/kg（P〈0.001）,RR从（23±6）次/min降至（16±3）次/min（P〈0.001）,气道峰压（Ppeak）从（29.2±2.3）cmH2O降至（22.6±2.5）cmH2O（P〈0.001）,PaO2从（77.4±5.8）mmHg升至（110.6±11.7）mmHg（P〈0.001）,PaCO2和pH基本无变化（P〉0.05）;24h后体温从（38±0.5）℃下降至（37.6±0.4）℃（P〈0.05）;5d后T降至（36.6±0.7）℃（P〈0.001）,白细胞从（15.3±3.2）×109/mm3下降至（8.6±2.5）×109/mm3（P〈0.001）,肺部渗出性病变所占比例从44%±9%减少至18.8%±3.6%（P〈0.001）。对照组除渗出性病变略减少外,其他指标皆无明显改善,两组结果比较差异皆有统计学意义（P〈0.05）。结论大潮气量通气能较快改善围手术期VAP患者的低氧血症和肺部感染。     

痰热清注射液对呼吸机相关性肺炎患者免疫因子和临床预后的影响研究

目的:研究痰热清注射液对呼吸机相关性肺炎(VAP)患者免疫因子和临床预后的影响。方法:155例VAP患者随机分为治疗组和对照组,治疗前和治疗后第1、3、5、7天检测血清CRP、IL-6、TNF-α的动态变化;比较治疗前和治疗后第3天X线胸片变化;统计机械通气(MV)时间、脱机成功率和死亡率。结果:155例VAP患者治疗前血清CRP、IL-6、TNF-α较正常水平均明显升高;治疗组在治疗后第5天血清IL-6、TNF-α水平较对照组开始显著下降(P<0.05);在第7天血清CRP、IL-6、TNF-α水平均较对照组显著下降(P<0.05));治疗组MV时间较对照组显著缩短(P<0.05);治疗组3d后X线胸片改善率、首次脱机成功率均显著高于对照组(P<0.05),死亡率显著低于对照组(P<0.05)。治疗组在治疗后第7天血清CRP、IL-6和TNF-α与MV时间呈正相关。结论:痰热清注射液在辅助治疗VAP中,通过抑制过度的炎症反应,恢复部分机体免疫功能,有助于减弱VAP后继发多脏器功能损害,从而缩短MV时间,降低死亡率,改善VAP预后。     

呼吸机在铁灭克中毒中的应用

目的探讨呼吸机在铁灭克中毒抢救治疗中的重要性。方法将78例铁灭克中毒按使用呼吸机的时间前后分为两组,第一组36例,第二组42例,两组均按常规治疗,包括：洗胃、导泻、阿托品化等治疗。第二组加用呼吸机抢救。结果第一组6例痊愈,30例死亡。第二组42例全部存活,于中毒48小时后顺利撤用呼吸机。结论早期建立人工气道及机械通气是抢救铁灭克急性中毒的重要措施。     

The Prediction of Extubation Success of Postoperative Neurosurgical Patients Using Frequency–Tidal Volume Ratios

Background  The process of discontinuing neurological patients from mechanical ventilation is still controversial. The aim of this study was to report the outcome from extubating patients undergoing elective craniotomy and correlate the result with the measured f/V _t ratio. Materials and Methods  In a cohort prospective study, all consecutive patients who required mechanical ventilation for up to 6 h after elective craniotomy were eligible for inclusion in this study. Patients passing daily screening criteria automatically received a spontaneous breathing trial (SBT). Immediately previous to the extubation, the expired minute volume (VE), breathing frequency (f), and tidal volume (V _t) were measured and the breathing frequency-to-tidal volume ratio (f/V _t) was calculated; consciousness level based on Glasgow Coma Scale (GCS) was evaluated at the same time. The extubation was considered a failure when patients needed reintubation within 48 h. Results  Ninety-two patients were extubated and failure occurred in 16%. Despite 15 patients failed extubation just one of them presented the f/V _t score over 105. The best cutoff value for f/V _t observed was 62, but with low specificity (0.53) and negative predictive values (0.29). Area under the ROC curve for the f/V _t was 0.69 ± 0.07 (P = 0.02). Patients who failed the extubation process presented higher incidence of pneumonia (80%), higher need for tracheostomy (33%) and mortality rate of 40%. Conclusion  The f/V _t ratio does not predict extubation failure in patients who have undergone elective craniotomy. Patients who fail extubation present higher incidence of pneumonia, tracheostomy and higher mortality rate.     

Predictors of ventilator weaning in individuals with high cervical spinal cord injury

BACKGROUND/OBJECTIVE: To evaluate which tests best predict the ability of patients with ventilator-dependent tetraplegia to wean from the ventilator. METHODS: Retrospective review of patients. PARTICIPANTS: Twenty-six ventilator-dependent patients with tetraplegia admitted to a university inpatient spinal cord-injury rehabilitation unit with American Spinal Injury Association (ASIA) injury levels C2 to C6, A or B. RESULTS: Failure to wean off the ventilator completely was predicted by absence of motor unit recruitment of one hemidiaphragm or at least moderate decreased recruitment with needle electromyography (EMG) in both hemidiaphragms. Phrenic nerve conduction studies would have predicted that all patients who weaned off the ventilator would have failed. Fluoroscopic examination of the diaphragm and bedside spirometry were not as good predictors of ability to wean, failing to predict accurately in 44% and 19% of cases, respectively. ASIA examination was also not entirely predictive, and any outliers that may have been expected to wean based on ASIA examination (ie, C4 or lower neurological levels) were predicted not to wean by needle electromyography. CONCLUSIONS: Negative inspiration force diaphragm needle EMG best predicted the ability to wean from the ventilator. Bedside spirometry (negative inspiratory force and forced vital capacity) is an accurate bedside measure of a patient's readiness to wean. Fluoroscopic examination of the diaphragm and phrenic nerve conduction studies were not helpful in determining weaning potential in ventilator-dependent patients with cervical spine injury.     

A 2-minute pre-extubation protocol for ventilated intensive care unit patients

Background

Clinicians often are challenged with safely predicting the optimal time of extubation for ventilated patients. Commonly used weaning parameters have poor positive predictive value for successful extubation.

Methods

A total of 213 intubated patients in our 20-bed surgical intensive care unit were enrolled in a trial to test a prospective, observational, 2-minute extubation protocol (TMEP). Daily measurements were obtained on all intubated patients who met criteria, which included adequate oxygenation, systolic blood pressure, heart rate, hemoglobin, Glasgow Coma Score greater than 10t, absence of significant metabolic/respiratory acidosis, and absence of therapeutic or neurologic paralysis. During TMEP, endotracheally intubated patients were physically disconnected from the ventilator for a 2-minute period of observation while spontaneously breathing room air. Patients were extubated if they tolerated the trial without clinically significant desaturation or alteration of vital signs or mental status.

Results

The TMEP reliably predicted successful extubations in 203 of 213 patients (95.3%). Patients who required reintubation had a longer intensive care unit stay and a longer hospital stay.

Conclusions

TMEP is a simple and reliable method of predicting successful extubation.     

Ventilator-associated pneumonia: Improving outcomes through guideline implementation

Ventilator-associated pneumonia (VAP) is associated with increased duration of mechanical ventilation and increased risk of death for critically ill patients. Although scientific advances have the potential to improve the outcomes of critically ill patients who are at risk of or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. Unfortunately, there remain large gaps in our understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP.     

Predictors of extubation failure in neurocritical patients: A systematic review

ObjectiveThe objective of this study was to identify predictors of extubation failure in neurocritical patients.MethodsThis was systematic review performed through a bibliographic search of the databases PubMed/Medline, Lilacs, SciELO, and Web of Science, from February 2020 to October 2021. Cohort studies that investigated the predictors of extubation failure were included, defined as the need for reintubation within 48 h after extubation, in adult neurocritical patients. The risk-of-bias assessment was performed using the Newcastle–Ottawa Scale, for cohort studies.ResultsEight studies, totaling 18 487 participants, were included. A total of 15 predictors for extubation failure in neurocritical patients have been identified. Of these, four were the most frequent: low score on the Glasgow Coma Scale (motor score ≤5, 8T–10T), female gender, time on mechanical ventilation (≥7 days, ≥ 10 days), and moderate or large secretion volume.ConclusionsIn addition to the conventional parameters of weaning and extubation, other factors, such as a low score on the Glasgow Coma Scale, female gender, mechanical ventilation time, and moderate or large secretion volume, must be taken into account to prevent extubation failure in neurocritical patients in clinical practice.