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2005| October-December | Volume 9 | Issue 4
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Mechanical ventilation: changing concepts
Pablo Rodriguez, Michel Dojat, Laurent Brochard
October-December 2005, 9(4):235-243
Mechanical ventilation is routinely delivered to patients admitted in intensive care units to reduce work of breathing, improve oxygenation, or correct respiratory acidosis. Although traditional modes of mechanical ventilation achieve many of these goals, they have important limitations. Alternative modes are supposed to handle some of these limitations and are now available on modern ventilators. This article reviews general aspects of functioning and limitations of traditional modes of mechanical ventilation, and the potential interest of some new promising modes.
Severe lung injury following inhalation of nitric acid fumes
Lalitha V Pillai, Dhananjay P Ambike, Saifuddin Husainy, Sunil Vishwasrao, Satish Pataskar, Suprashant D Kulkarni
October-December 2005, 9(4):244-247
We present a rare case of survival following inhalation of nitric acid fumes and its decomposition products, which resulted in severe pulmonary edema and Acute Respiratory Distress Syndrome (ARDS). Successful outcome followed ventilatory support and use of steroids.
Tertiary-level medical intensive care unit.
A single case of inhalation of nitric oxide fumes.
Ventilatory support and addition of steroids.
Measurement and main results:
Improvement and discharge.
Inhalation of nitric acid fumes and its decomposition gases such as nitrogen dioxide results in delayed onset of severe pulmonary edema deteriorating into ARDS. Intensive respiratory management, ventilatory support, and steroids can help in survival.
Acute respiratory failure in asthma
Said H Soubra, Kalapalatha K Guntupalli
October-December 2005, 9(4):225-234
Although asthma is a condition that is managed in the outpatient setting in most patients, the poorly controlled and severe cases pose a major challenge to the health-care team. Recognition of the more common insidious and the less common rapid onset "acute asphyxic" asthma are important. The intensivist needs to be familiar with the factors that denote severity of the exacerbation. The management of respiratory failure in asthma, including pharmacologic and mechanical ventilation, are discussed in this article. Two important complications of the positive-pressure ventilation, the dynamic hyperinflation and barotrauma, may be life-threatening. Interventions with helium-oxygen mixtures, anesthesia, and paralysis may be considered in certain situations.
Comparision of two ventilation modes and their clinical implications in sick children
Anil Sachdev, Krishan Chugh, Dhiren Gupta, Shruti Agarwal
October-December 2005, 9(4):205-210
To compare the ventilation parameters of conventional, volume-controlled (VC), and pressure-regulated volume-controlled modes in sick children with varying lung disease, the effects of specific mode on ventilation-related complications and patient outcome, and improvement in oxygenation with any specific mode.
Retrospective case record analysis.
Seven-bedded tertiary-care pediatric intensive care unit in North India.
Twenty-eight ventilated children admitted from July to December 2000.
Measurements and Main Results:
Twenty-eight patients were studied with equal number in VC and pressure-regulated (PR) VC groups. The demographic profile, as well as preventilation and on ventilator blood-gas analysis were comparable in the two groups. Mean airway pressure in PRVC group was 17.5% lower as compared with that in VC group (
= 0.03). Similarly, preventilation PaO2 (65 ± 17 mmHg), PaO2/FiO2 (121 ± 41 mmHg), and respiratory index (RI) (4.91 ± 2.7) improved significantly (P<0.05) with PRVC ventilation (PaO2 = 99 ± 25 mmHg, PaO2/FiO2 = 183 ± 8 mmHg, RI = 3.36±2.95) and not in VC ventilation group. There was no difference in duration of ventilation, ventilator-related complications, and patient outcome in the two groups.
PRVC ventilation is beneficial and improves oxygenation in initial stages of ventilation.
Noninvasive ventilation for hypercapnic respiratory failure in COPD : Encephalopathy and initial post-support deterioration of pH and PaCO2 may not predict failure
Raj Kumar Mani
October-December 2005, 9(4):217-224
To correlate the degree of encephalopathy, baseline values of PaCO2 and pH, and their early response to NIV with eventual in-hospital outcome in patients of severe acute-on-chronic hypercapnic respiratory failure in COPD.
Intensive care unit.
Material and methods:
24 episodes of acute exacerbation of COPD in 17 patients (10 females, 7 males) with a mean age of 59.5 years (range 48 - 82) where NIV was initiated. Data collected: encephalopathy score at baseline and at 24 hours, respiratory rate, breathing pattern, serial arterial blood gases, duration of NIV support per day and hospital days.
All patients had severe hypercapnia (mean peak PaCO2 89.0 mm Hg ± 21; range 66-143), respiratory acidosis (mean nadir pH 7.24 ± 0.058, range 7.14 - 7.33) and tachypnoea (mean respiratory rate 29.5 ± 4.69/mt; range 24 - 40). In 17 episodes, altered mental state was present (encephalopathy score 1.92 ± 1.32, median 2.5). Clinically stable condition occurred over several days (mean 13± 9.6 days; range 5 - 40). Intubation was avoided in 22 out of 24 episodes (91.6%) despite significant initial worsening of PaCO2 and pH. Two patients died. The mean time on NIV was16.5 hours/day (range 4 - 22).
In selected patients of COPD with acute hypercapnic failure on NIV worsening PaCO2 and pH in the initial hours may not predict failure provided the level of consciousness and respiratory distress improve.
Incidence, clinical outcome, and risk stratification of ventilator-associated pneumonia-a prospective cohort study
Panwar Rakshit, Vidya S Nagar, Alaka K Deshpande
October-December 2005, 9(4):211-216
Context and Aim:
Ventilator-associated pneumonia (VAP) remains to be the commonest cause of hospital morbidity and mortality in spite of advances in diagnostic techniques and management. This project aims to study the various risk factors and the common microbial flora associated with VAP. It also evaluates the use of APACHEIII scores for prognostication.
A prospective cohort study was conducted over 1 year in medical critical care unit (CCU) of a tertiary-care teaching hospital.
Methods and Material:
VAP was diagnosed using the clinical pulmonary infection score (CPIS) of more than 6. The study cohort comprised 51 patients. All CCU patients requiring mechanical ventilation for more than 48 h formed the study group.
Statistical Analysis Used:
Univariate analysis, c2-test, and paired "
Twenty-four out of fifty-one cases developed VAP. These cases had an average APACHEIII score of more than 55 on admission to critical care unit (CCU). They needed prolonged mechanical ventilation and had lower PaO2/FiO2 ratio as compared with the remaining patients who did not develop VAP. Pseudomonas aeroginosa was the commonest and most lethal organism. The mortality in the VAP group was 37% and correlated very well with higher APACHEIII scores on admission.
Longer duration of mechanical ventilation and the need of reintubation are associated with proportionate rise in the incidence of VAP. Deteriorating PaO2/FiO2 ratio correlated well with the onset of VAP. Higher APACHEIII scores on admission stratify the mortality risk.
Low tidal volume ventilation in acute respiratory distress syndrome
Ashwini Jahagirdar, Shirish Prayag
October-December 2005, 9(4):189-194
Effect of low tidal volumes vs conventional tidal volumes on outcomes of acute respiratory distress syndrome in critically ill children
Praveen Khilnani, Mritunjay Pao, Deepika Singhal, Ruchi Jain, Anita Bakshi, Rajiv Uttam
October-December 2005, 9(4):195-199
Adult data have shown low tidal volume strategy to be beneficial to the outcome of acute respiratory distress syndrome (ARDS).There are little data regarding the effect of different tidal volume strategies on outcomes in children with ARDS.
Aims and Objectives:
The aim of this study was to learn the differences in outcomes from ARDS in children using low vs conventional tidal volumes.
All patients with ARDS (aged 1 month to 16 years) admitted to the pediatric intensive care unit from March 98 to June 2004 were studied. Prospective data for low expired tidal volumes (6-8ml/kg) were collected from Jan 2001 to June 2004 (group 1). ARDS patients during March 1998 to December 2000, receiving conventional tidal volumes (10-15 ml/kg) were used as retrospective control (group 2). Etiologies, PRISMIII scores, interventions, and outcomes data were recorded. Standard supportive therapy for ARDS was used in all children using conventional mechanical ventilation.
A total of 153 (4.67%) patients had ARDS as defined by standard criteria. Groups 1 and 2 had 78 and 65 patients, respectively, with comparable PRISMIII scores. Mortality was 23% (group 1) vs 36.9% (group 2) (
<0.005). The mean duration of ventilation and hospitalization in group 1 was significantly lower when compared with group 2 (11
<0.005) and group 1 (19
<0.005), respectively. Incidence of pneumothorax was 5% (group 1) as compared with 12% (group 2) (
<0.01). Long-term follow-up for incidence of chronic lung disease could not be studied. Common etiologies of ARDS included pneumonia, sepsis, dengue shock syndrome, falciparum malaria, and fulminant hepatic failure.
Low tidal volume strategy was found to be associated with significantly lower duration of ventilation, hospitalization, incidence of pneumothorax, and mortality when compared with conventional tidal volume strategy in children with ARDS.
Identification of preadmission predictors of outcome of noninvasive ventilation in acute exacerbation of chronic obstructive pulmonary disease
Mohd. Shameem, Rakesh Bhargava, Zuber Ahmad
October-December 2005, 9(4):200-204
Noninvasive ventilation (NIV) has been shown to be an effective treatment for ventilatory failure, particularly resulting from acute exacerbations of chronic obstructive pulmonary disease (COPD). However, NIV is associated with significant failure rates. Hence, there is a need for identifying preadmission predictors for outcome of NIV in patients for acute exacerbation of COPD, thereby sparing the discomfort of a trial of NIV on these patients.
The study was carried to identify the preadmission predictors of outcome of NIV in acute exacerbation of COPD with respiratory failure.
Material and Methods:
The study was carried in the Department of TB & Chest diseases at the Jawaharlal Nehru Medical College, AMU; 250 patients with acute exacerbation of COPD were enrolled in the study. These patients were grouped on the basis of six different independent variables, viz. age, performance status, pH, late failures, SaO2, and presence or absence of pedal edema. Analysis was done by z-test, P<0.001 was considered significant.
Age had no impact on the outcome of patient on NIV (
= 0.3).The risk for endotracheal intubation was found to be increased by the presence of pedal edema (
= 6.2; P < 0.001), O2 saturation of less than 86% (
= 4.7; P < 0.001), and acidemia (pH < 7.3) on admission (
= 10.6; P < 0.001). In addition, poor performance status of limited self-care (
= 3.2; P < 0.01) and late failures carried poor outcome of NIV (
= 8.3; P < 0.001).
Patients' COPD with poor baseline performance status, pedal edema, low oxygen saturation, and academia carry a high likelihood of failure and should be spared a prolonged trial of NIV.
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