Tag Archives: mechanical ventilation

Inhaled Nitric Oxide in Patients with Severe COVID-19 Infection at Intensive Care Unit – A Cross-Sectional Study

DOI: 10.2478/jccm-2021-0033

In adults with severe hypoxemia, inhaled nitric oxide (iNO) is known to reduce pulmonary shunt and pulmonary hypertension, improving V/Q matching(1). Studies in refractory hypoxemia among patients with severe acute respiratory distress syndrome (ARDS) suggest that iNO may be allied to other ventilatory strategies as a bridge to clinical improvement(2, 3).
A trial from the 2004 Beijing Coronavirus Outbreak showed that low dose iNO could shorten the time of ventilatory support(4). Additionally, preclinical studies suggest an inhibitory effect of iNO on viral replication(5). To date, the role of iNO in COVID19 infection is still unclear. [More]

Full text: PDF

The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured patients

DOI: 10.2478/jccm-2021-0014

Background: Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI.
Method: This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4).
Results: The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours.
Conclusion: In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.

Full text: PDF

The Use of Diuretic in Mechanically Ventilated Children with Viral Bronchiolitis: A Cohort Study

DOI: 10.2478/jccm-2021-0008

Introduction: Viral bronchiolitis is a leading cause of admissions to pediatric intensive care unit (PICU). A literature review indicates that there is limited information on fluid overload and the use of diuretics in mechanically ventilated children with viral bronchiolitis. This study was conducted to understand diuretic use concerning fluid overload in this population.
Material and methods: A retrospective cohort study performed at a quaternary children’s hospital. The study population consisted of mechanically ventilated children with bronchiolitis, with a confirmed viral diagnosis on polymerase chain reaction (PCR) testing. Children with co-morbidities were excluded. Data collected included demographics, fluid status, diuretic use, morbidity and outcomes. The data were compared between groups that received or did not receive diuretics.
Result: Of the 224 mechanically ventilated children with confirmed bronchiolitis, 179 (79%) received furosemide on Day 2 of invasive ventilation. Out of these, 72% of the patients received intermittent intravenous furosemide, whereas 28% received continuous infusion. It was used more commonly in patients who had a higher fluid overload. Initial fluid overload was associated with longer duration of mechanical ventilation (median days 6 vs 4, p<0.001) and length of stay (median days 10 vs 6, p<0.001) even with the use of furosemide. Superimposed bacterial pneumonia was seen in 60% of cases and was associated with a higher per cent fluid overload at 24 hours (9.1 vs 6.3, p = 0.003).
Conclusion: Diuretics are frequently used in mechanically ventilated children with bronchiolitis and fluid overload, with intermittent dosing of furosemide being the commonest treatment. There is a potential benefit of improved oxygenation in these children, though further research is needed to quantify this benefit and any potential harm. Due to potential harm with fluid overload, restrictive fluid strategies may have a potential benefit.

Full text: PDF

Mortality Rate and Predictors among Patients with COVID-19 Related Acute Respiratory Failure Requiring Mechanical Ventilation: A Retrospective Single Centre Study

DOI: 10.2478/jccm-2020-0043

Aim: The objective of the study was to assess mortality rates in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) who also requiring mechanical ventilation. The predictors of mortality in this cohort were analysed, and the clinical characteristics recorded.
Material and method: A single centre retrospective study was conducted on all COVID-19 patients admitted to the intensive care unit of the Epicura Hospital Center, Province of Hainaut, Belgium, between March 1st and April 30th 2020.
Results: Forty-nine patients were included in the study of which thirty-four were male, and fifteen were female. The mean (SD) age was 68.8 (10.6) and 69.5 (12.6) for males and females, respectively. The median time to death after the onset of symptoms was eighteen days. The median time to death, after hospital admission was nine days. By the end of the thirty days follow-up, twenty-seven patients (55%) had died, and twenty–two (45%) had survived. Non-survivors, as compared to those who survived, were similar in gender, prescribed medications, COVID-19 symptoms, with similar laboratory test results. They were significantly older (p = 0.007), with a higher co-morbidity burden (p = 0.026) and underwent significantly less tracheostomy (p < 0.001). In multivariable logistic regression analysis, no parameter significantly predicted mortality.
Conclusions: This study reported a mortality rate of 55% in critically ill COVID-19 patients with ARDS who also required mechanical ventilation. The results corroborate previous findings that older and more comorbid patients represent the population at most risk of a poor outcome in this setting.

Full text: PDF

Mechanical Ventilation – A Friend in Need?

DOI: 10.2478/jccm-2020-0027

The development of modern medicine has imposed a new approach both in anaesthesiology and in intensive care. This is the reason why, in the last decades, more and more devices and life-support techniques were improved in order to achieve the highest medical outcomes.
Key features of the critically ill patient are severe respiratory, cardiovascular or neurological derangements, often in combination, reflected in abnormal physiological observations. All these changes converge towards the establishment of pulmonary or extrapulmonary respiratory failure requiring mechanical ventilatory support. In the current conception, mechanical ventilation does not represent a curative method for respiratory pathology, however, it represents a bridge therapy ensuring the rest and preservation of respiratory muscles, improves gas exchange and assists in maintaining a normal pH until the recovery of the patient [1].
Despite decades of research, there are limited therapeutic options directed towards the underlying pathological processes and supportive care with mechanical ventilation remaining the cornerstone of patient management. [More]

Full text: PDF

Accidental Modopar© Poisoning in a Two-Year-Old Child. A Case Report

DOI: 10.2478/jccm-2019-0024

Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson’s disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.

Full text: PDF

Influence of Ventilation Parameters on Intraabdominal Pressure

DOI: 10.1515/jccm-2016-0016

Introduction: Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.
Objectives: To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index.
Material and method: This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.
Results: We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).
Conclusions: The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

Full text: PDF

Predictors Of Mortality In Patients With ST-Segment Elevation Acute Myocardial Infarction And Resuscitated Out-Of-Hospital Cardiac Arrest

DOI: 10.1515/jccm-2016-0001

Introduction: In patients with out-of-hospital cardiac arrest (OHCA) complicating an ST-segment elevation myocardial infarction (STEMI), the survival depends largely on the restoration of coronary flow in the infarct related artery. The aim of this study was to determine clinical and angiographic predictors of in-hospital mortality in patients with OHCA and STEMI, successfully resuscitated and undergoing primary percutaneous intervention (PCI).
Methods: From January 2013 to July 2015, 78 patients with STEMI presenting OHCA, successfully resuscitated, transferred immediately to the catheterization unit and treated with primary PCI, were analyzed. Clinical, laboratory and angiographic data were compared in 28 non-survivors and 50 survivors.
Results: The clinical baseline characteristics of the study population showed no significant differences between the survivors and non-survivors in respect to age (p=0.06), gender (p=0.8), the presence of hypertension (p=0.4), dyslipidemia (p=0.09) obesity (p=1), smoking status (p=0.2), presence of diabetes (p=0.2), a clinical history of acute myocardial infarction (p=0.7) or stroke (p=0.17). Compared to survivors, the non-survivor group exhibited a significantly higher incidence of cardiogenic shock (50% vs 24%, p=0.02), renal failure (64.3% vs 30.0%, p=0.004) and anaemia (35.7% vs 12.0%, p=0.02). Three-vessel disease was significantly higher in the non-survivor group (42.8% vs. 20.0%, p=0.03), while there was a significantly higher percentage of TIMI 3 flow postPCI in the infarct-related artery in the survivor group (80.% vs. 57.1%, p=0.03). The time from the onset of symptoms to revascularization was significantly higher in patients who died compared to those who survived (387.5 +/- 211.3 minutes vs 300.8 +/- 166.1 minutes, p=0.04), as was the time from the onset of cardiac arrest to revascularization (103.0 +/- 56.34 minutes vs 67.0 +/- 44.4 minutes, p=0.002). Multivariate analysis identified the presence of cardiogenic shock (odds ratio [OR]: 3.17, p=0.02), multivessel disease (OR: 3.0, p=0.03), renal failure (OR: 4.2, p=0.004), anaemia (OR: 4.07, p=0.02), need for mechanical ventilation >48 hours (OR: 8.07, p=0.0002) and a duration of stay in the ICU longer than 5 days (OR: 9.96, p=0.0002) as the most significant independent predictors for mortality in patients with OHCA and STEMI.
Conclusion: In patients surviving an OHCA in the early phase of a myocardial infarction, the presence of cardiogenic shock, renal failure, anaemia or multivessel disease, as well as a longer time from the onset of symptoms or of cardiac arrest to revascularization, are independent predictors of mortality. However, the most powerful predictor of death is the duration of stay in the ICU and the requirement of mechanical ventilation for more than forty-eight hours.

Full text: PDF

Acquired Tracheal Diverticulum as an Unexpected Cause of Endotracheal Tube Cuff Leak

DOI: 10.1515/jccm-2015-0024

Introduction: Tracheal diverticulum has been associated with problems during endotracheal intubation but there are no reports concerning air leakage around an endotracheal tube (ETT).
Case report: The case of an elderly woman under mechanical ventilatory support because an exacerbation of chronic obstructive pulmonary disease (COPD) is reported. She presented with an inexplicably air leak around the endotracheal tube not attributed to structural defects. The intra-cuff pressure value was as high as 30 mmHg to prevent an air leakage. Bronchoscopy revealed a tracheal diverticulum at the site ofthe tube cuff that allowed air leakage around it. The problem was overcome by re-intubating the patient with a larger diameter tube and positioning its distal end above the diverticular opening.
Discussion: Endotracheal tube air leak is a frequently neglected problem. COPD and other inflammatory conditions are associated with changes in the elastic properties of the airways resulting in tracheomegaly or acquired tracheal diverticulum. Both entities have been linked to problems during intubation or ventilation of patients. However tracheal diverticulum has not been described previously as a cause of air leakage.
Conclusion: Acquired tracheal diverticulum should be recognized as a cause of air leakage in the intubated patient, especially if associated with a normal or elevated intracuff pressure.

Full text: PDF