Effect of Timing of Tracheotomy on Clinical Outcomes: an Update Meta-analysis Including 11 Trials

Objective To estimate the relative effect of early vs. late tracheotomy on clinical end-points in unselected intensive care unit （ICU） patients undergoing mechanical ventilation. Methods We searched electronic databases （up to February 27, 2013） for both randomized control trials and observational studies satisfying the predefined inclusion criteria.

Need for oxygen therapy and ventilatory support in premature infants in a hospital in Southern Brazil

BACKGROUND Prematurity in newborns is a condition that is associated with worse hospital outcomes when compared to birth to term.A preterm infant(PI)is classified when gestational age(GA)<37 wk.AIM To analyze prognostic indicators related to the use of oxygen therapy,noninvasive ventilation(continuous positive airway pressure)and mechanical ventilation(MV)in PI.METHODS This is a retrospective cohort.The sample was composed of PIs from a private hospital in southern Brazil.We included neonates with GA<37 wk of gestation in the period of January 1,2018 to December 31,2018.For data collection,electronic records were used in the Tasy Philips^(TM)system,identifying the variables:maternal age,type of birth,prenatal information,GA,Apgar score,birth weight,neonatal morbidities,vital signs in the 1st hour at birth,need for oxygen therapy,continuous positive airway pressure and MV,hospitalization in the neonatal intensive care unit,length of stay and discharge or death.RESULTS In total,90 PI records were analyzed.The median(p25-p75)of GA was 34.0(31.9-35.4)wk,and there were 45(50%)males.The most common morbidity among PIs was the acute respiratory discomfort syndrome,requiring hospitalization in the neonatal intensive care unit in 76(84.4%)cases.The utilization rate of oxygen therapy,continuous positive airway pressure and MV was 12(13.3%),37(41.1%)and 13(14.4%),respectively.The median(p25-p75)length of stay was 12.0(5.0-22.2)d,with 10(11.1%)deaths.A statistical association was observed with the use of MV and GA<28 wk,lower maternal age,low birth weight,Apgar<8 and neonatal deaths.CONCLUSION The identification of factors related to the need for MV in prematurity may help in the indication of a qualified team and technologies to promptly meet the unforeseen events that may occur after birth.

Distribution of ventilation and hemodynamic effects of different ventilatory patterns

OBJECTIVE: To compare the influence of cardiac-pulmonary function on clinical acute respiratory failure patients using Proportional assist ventilation (PAV), Pressure support ventilation (PSV) and intermittent positive pressure ventilation (IPPV). Here, we also describe some our experience with the clinical use of PAV. METHODS: Using the IPPV mode in ten acute respiratory failure patients, calculate Elastance (Ers) and Resistance (Rrs), then change to PSV, set inspiratory positive airway pressure (IPAP) according to IPPV, so that tidal volume (V(T)) is the same as that of IPPV. We then changed the mode into PAV and set the assist ratio according to PSV, so that V(T) and Ppeak were the same as that of PSV. Then we observed the changes of respiratory mechanics, blood gas levels and hemodynamics during ventilation. RESULTS: Compared with PSV and IPPV, peak pressure (Ppeak) of PAV was markedly lower while V(T) was similar; work of breathing of patient (WOBp), and work of breathing of ventilation (WOBv) were also lower; center vein pressure (CVP) and pulmonary capillary wedge pressure (PCWP) of PAV were markedly lower than that of IPPV while V(T) were similar. Compared with PSV, V(T), mean blood pressure (mBP) and cardiac output (CO) of PAV were higher. Mean pulmonary artery pressure (mPAP) and WOBp of PAV were lower while Ppeak was similar; the differences in WOBp were notable. CONCLUSIONS: For clinical acute respiratory failure patients, compared with PSV and IPPV, PAV has lower airway pressure, less WOBp and less influence on hemodynamics.

Proportional assist ventilation: methodology and therapeutics on COPD patients compared with pressure support ventilation

OBJECTIVE: To investigate the impact of proportional assist ventilation (PAV) on tolerance and breathlessness in ventilated chronic obstructive pulmonary disease (COPD), and to describe the patient-ventilator interaction, hemodynamic state, breathing pattern and work of breath during PAV and pressure support ventilation (PSV). METHODS: Ten intubated COPD patients on weaning from mechanical ventilation were studied. Elastance and resistance were measured by both the inspiratory-hold technique during a brief period of volume control ventilation and runaway technique during PAV. Each assistance level of PAV (80%, 60% and 40%) and PSV was selected randomly. Patients' response, hemodynamics, blood gas and lung mechanics were monitored. RESULTS: Tidal volume and respiratory rate didn't change in a consistent manner as the level of assist was decreased (P > 0.05). With the level of assist increasing, peak inspiratory pressure was increasing significantly (P

Clinical efficacy and safety of recruitment maneuver in patients with acute respiratory distress syndrome using low tidal volume ventilation： a multicenter randomized controlled clinical trial

Background The recruitment maneuver （RM） has been shown to improve oxygenation in some patients with acute respiratory distress syndrome. But there is a lack of standardization and lack of clinical studies to prove the improvement on clinical outcome. We conducted this study to evaluate the clinical efficacy and safety of the RM in patients with acute respiratory distress syndrome （ARDS） using Iow tidal volume ventilation.Methods We randomly assigned 110 patients with ARDS from 14 Chinese intensive care units （ICUs） at the tertiary teaching hospitals. Patients with PaO2 ≤200 mmHg at FiO2 1.0 and PEEP ≥10 cmH2O were included in the study.Patients were randomized into two groups： control group and RM group. The tidal volume was set to 6-8 mi per kilogram of predicted body weight （PBW） in both groups. RM was performed by continuous positive airway pressure （CPAP） of 40 cmH2O maintained for 40 seconds. RMs was conducted every eight hours for the first five days, or stopped within five days if the patient reached the weaning standard.Results One hundred and ten patients had completed the requirements for the primary study goals, 55 from the RM group and 55 control patients. Baseline characteristics remained similar in the two groups. In the RM group the PaO2/FiO2 was significantly increased compared to baseline at 120 minutes after RM on day one and day two （P=0.007and P=0.001）. There were no significant differences between the RM and control group in hospital mortality （41.8% vs.56.4%, P=0.13）, 28-day mortality （29.1% vs. 43.6%, P=0.11） and ventilator-free days at day 28 （10.8±10.1 vs. 7.4±10.0,P=0.08）. ICU mortality （32.7% vs. 52.7%, P=0.03）, the rate of survival with unassisted breathing for at least 48 consecutive hours at day 28 （58.2% vs. 36.2%, P=0.02）, and nonpulmonary organ failure-free days at day 28 （17.4±11.1vs. 13.0±12.0, P=0.03） favored the RM group. There was no significant difference in mean blood pressure and heart rate before RM and at 30, 60, 120 minutes after RM. There was no incidence of barotraumas.Conclusions RM was safe and useful for improving oxygenation in patients with ARDS who were ventilated with a low tidal volume, with a beneficial impact on their clinical outcome.

SARS treatment; experience from a team in Guangdong, China

The epidemic of SARS in Guangdong province of China isbeginning to be restrained. In May 2003, Dr. ZhongNanshan, head of the Guangzhou Institute of RespiratoryDisease, presented at a training course in Beijing for

Changes of dipalmitoyl phosphatidyl choline after mechanical ventilation in patients with acute cerebral injury

Objective： To detect the levels of dipalmitoyl phosphatidyl choline （DPPC） in the sputum of the patients with acute cerebral injury without primary pulmonary injury after mechanical ventilation treatment. Methods： DPPC levels in sputum of 35 patients with acute cerebral injury but without pulmonary injury were detected with high performance liquid chromatography at the beginning of ventilation and 16-20 days, 21-40 days, and 41-60 days after ventilation, respectively. Results： There was no significant difference of the DPPC levels between 16-20 days after ventilation （3.36±0.49） and at the beginning of ventilation （3.37 ± 0.58 ） （P〉0.05）. The mean levels of DPPC decreased significantly at 21-40 days （2.87 mg/ml ±0.26 mg/ml, P〈0.05） and 41-60 days （1.93 mg/ml ±0.21 mg/ml, P〈0.01 ） after ventilation compared with that at the beginning of ventilation. At the same period, the peak inspiratory pressure and the mean pressure of airway increased significantly, whereas the static compliance and the partial pressure of oxygen in artery decreased significantly. Among the 25 patients who received ventilation for more than 20 days, 8 （32%） had slightly-decreased partial pressure of oxygen in artery compared with that at the beginning of ventilation. Conclusions： Mechanical ventilation can decrease the DPPC levels, decrease the lung compliance and increase the airway pressure, even impair the oxygenation function in patients with acute cerebral injury. Abnormal DPPC is one of the major causes of ventilator-associated lung injury.