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PubMed1997

[Noninvasive ventilation in the acute care hospital--a cost factor?].

BACKGROUND: Noninvasive ventilation as well established in treatment of chronic respiratory failure. Many announcements and our own experience give evidence that this method of treatment is useful for patients with acute respiratory failure too. Also the actual situation of our health system requires increasing attention to financial points of view. PATIENTS AND METHOD: We analyzed a number of 185 patients who needed mechanical ventilation in our intensive care unit in 1995. 80 of these 185 needed mechanical ventilation due to pulmonary and cardiopulmonary diseases (e. g. cardiac failure, exacerbation of chronic obstructive lung disease, pneumonia and status asthmaticus). 61 received invasive, 19 noninvasive ventilation. RESULTS: Nineteen of 61 patients with invasive and 1 of 19 with noninvasive ventilation died. The mean duration of ventilation was 8.9 (1-50) days in the invasive ventilated group and 2.9 (1-8) days in the noninvasive ventilated group. A cost reduction of nearly 10000 Marks per patient can be calculated, using noninvasive ventilation due to the shorter duration of treatment. CONCLUSION: So noninvasive ventilation is a cost reducing and gentle alternative compared to conventional invasive mechanical ventilation for many patients with acute respiratory failure. It is also practicable in regional hospitals. Further investigation is needed to specify those groups of patients who receive the most benefit from noninvasive ventilation.

Cost-Benefit Analysis↗

PubMed1998

Reducing the duration of mechanical ventilation: three examples of change in the intensive care unit.

Mechanical ventilation is one of the most common medical therapies administered within ICUs. Similarly, the "weaning" or "liberation" of patients from mechanical ventilation is a common and extremely important task performed in ICUs and specialized ventilator units within hospitals. Various methods exist for assessing a patient's readiness to be liberated from mechanical ventilation and for conducting the weaning process. Clinicians working in ICUs frequently develop their own personal preferences regarding the best approach to weaning patients from ventilatory support. Therefore, variability in the practice of weaning patients from mechanical ventilation is frequently demonstrated, even within a single ICU. Recently, several randomized clinical trials have produced conflicting results regarding the best technique for carrying out the weaning process (e.g., spontaneous breathing trials, intermittent mandatory ventilation, pressure-support ventilation). Such conflicting findings have further illustrated the complexity of the weaning process and the difficulties in identifying the "best" medical practices for carrying out this endeavor. However, other investigations have suggested that the selection of an individual technique for weaning patients from mechanical ventilation may not be as important as employing a systematic approach to this medical process. Protocol-guided weaning of mechanical ventilation in the ICU setting, often performed by nonphysicians, has gained in acceptance as a result of these investigations. We describe the recent experiences of three ICUs which have demonstrated significant improvements in patient outcomes (e.g., shorter durations of mechanical ventilation, lower incidence of ventilator-associated pneumonia, fewer patient complications) as a result of implementing formal weaning protocols. Our hope is that these data will assist other hospitals in developing their own systematic guidelines and protocols for weaning patients from mechanical ventilation.

Clinical Protocols↗

PubMed2002

Respiratory mechanical unloading and proportional assist ventilation in infants.

UNLABELLED: Conventional patient-triggered ventilation attempts to synchronize the upstroke in ventilator pressure with the onset of spontaneous inspiration. Other parameters of the mechanical cycle such as the peak inspiratory pressure are preset by the clinician. They will be imposed on the infant regardless of the actual spontaneous respiratory drive. Proportional assist ventilation (PAV) and respiratory mechanical unloading of spontaneous breathing (RMU, resistive and elastic unloading) are based on fundamentally different concepts. In contrast to the conventional perception of the ventilator being a pump, RMU/PAV servo-controls the applied ventilator pressure continuously throughout each inspiration. These modalities proportionally enhance the effect on ventilation of each respiratory effort. They rely on rather than interfere with the subject's respiratory control system. The patient controls all variables of the respiratory pattern while the ventilator works fully enslaved as a proportional amplifier. Back-up conventional mechanical ventilation is initiated during episodes of hypoventilation and apnoea. The clinician sets the degree of the assist during RMU/PAV in terms of "gains". Selecting specific gains for the elastic and resistive unloading components allows the ventilator pressure waveform to be tailored to the individual degree of restrictive and obstructive pulmonary disease. This results in a reduction in the transpulmonary pressure cost of ventilation compared with conventional modes. CONCLUSION: Further studies on RMU/PAV are required to evaluate clinically important long-term outcome variables in infants and to determine whether the benefits outweigh potential drawbacks and the complexity involved in these new modes of mechanical ventilation.

Airway Resistance↗

PubMed1996

Effects of local restriction of evaporation and moderate local ventilation on thermoregulatory responses in exercising humans.

Ten healthy young men participated in two series of three trials: series 1 (C1) with, or without, local restriction of evaporation (either on the trunk or on the legs) and series 2 (C2) with, or without, local moderate nitrogen ventilation (40 l.min-1) under an impermeable garment (trunk or leg ventilation). After 60-min rest in a thermoneutral environment, the subjects exercised in a warm environment [30 degrees C, 47% relative humidity (rh) during C1 and 29% rh during C2] on a cycle ergometer for 60 min at 70 W during C1 or at 60 W during C2. During C1, local covering with plastic foil did not increase internal temperature, but increased the mean skin temperature with a higher effect in the case of leg restriction. The trunk skin temperature was affected by the leg covering while the leg skin temperature was not changed by the trunk covering. Only the local sweat rate of the trunk was increased by the two restriction conditions. During C2, internal temperature was decreased by local ventilation while mean skin temperature was reduced only by trunk ventilation. The local ventilation affected only trunk skin temperature with a greater decrease during trunk ventilation. Trunk ventilation did not influence the skin temperature of the legs while ventilation of the legs decreased trunk skin temperature. In addition, leg ventilation decreased the sweat rate of the legs. The impermeable suit worn during C2 led to a greater physiological strain compared to the plastic film worn during C1 even with local ventilation under the impermeable garment. As expected, limiting sweat evaporation led to an increase in physiological strain. Microclimate ventilation at a rate of 40 l.min-1 was not sufficient to allow total heat dissipation but allowed 60-min exercise in a warm environment to be completed without excessive heat accumulation. It would appear that ventilation of the trunk locally was the best solution because of the smaller increase in skin temperature and higher sweating capacity of the trunk.

Adult↗

PubMed1987

Ventilation performance using a self-inflating anesthesia bag: effect of operator characteristics.

Adequate ventilation is required for successful cardiopulmonary resuscitation (CPR). Operator characteristics that influence ventilation performance are not well defined. This study compared ventilation performance and operator characteristics in 74 medical personnel using a self-inflating anesthesia bag. Ventilation device, operator hand size, ventilation technique, average tidal volume, cumulative minute ventilation, and ventilation pressures were recorded during 3 minutes of ventilation. Ventilation volumes and airway pressures were not correlated with hand size or device type. Techniques that used one hand to squeeze the bag resulted in significantly lower average tidal volume than two-handed techniques, with no significant difference in peak or average airway pressure. There was no difference between emergency department and prehospital personnel in average tidal volume delivered. However, prehospital personnel ventilated at significantly higher airway pressures. Emergency department nurses delivered the greatest average tidal volume (923 cc), while emergency department physicians delivered the least (775 cc). Paramedics recorded the highest airway pressures (average, 53 cm H2O; peak, 72 cm H2O), while respiratory therapists recorded the lowest pressures (average, 34 cm H2O; peak, 54 cm H2O). Ventilation during CPR is a complex, learned skill. Large variation exists among different operators. However, appropriate tidal volumes can be delivered using safe airway pressures. Ongoing assessment and retraining of individuals performing ventilation during CPR are essential.

Adult↗

PubMed2004

[Practical and technical aspects of noninvasive ventilation].

INTRODUCTION: Noninvasive ventilation refers to the delivery of positive pressure ventilation via a mask or "interface" rather than via an invasive conduit. Until recently, equipment for noninvasive ventilation was frequently custom-made to meet the needs of an individual patient. During the past 15 years, there have been significant advances in the equipment available for noninvasive ventilation. STATE OF THE ART: Interfaces that have been designed specifically for noninvasive ventilation are now commercially available from several manufacturers. Commonly used interfaces include nasal and full face masks, and mouthpieces. The main characteristics, and potential advantages and disadvantages of each interface are described. Portable volume-limited or pressure-limited ventilators are available for home noninvasive ventilation. As with critical care ventilators, home mechanical ventilators are capable of delivering a variety of modes of ventilation. Furthermore, they are lightweight and economical. Technical aspects of ventilator circuits are also discussed here and some practical considerations about selection and maintenance of materials are proposed. CONCLUSIONS: Although major technical advances have been made, optimal delivery of noninvasive ventilation requires knowledge of, and experience with, the application of the equipment used.

Equipment Design↗

PubMed2003

Clinical experience with adaptive support ventilation for fast-track cardiac surgery.

OBJECTIVE: To evaluate adaptive support ventilation (ASV), an automatic microprocessor-controlled mode of mechanical ventilation, for the initial ventilatory management in consecutive patients eligible for early extubation after cardiac surgery. DESIGN: Prospective observational study. SETTING: Nonuniversity cardiac center. PARTICIPANTS: One hundred fifty-five consecutive patients eligible for early tracheal extubation after cardiac surgery. INTERVENTIONS: On intensive care unit arrival, patients were ventilated by adaptive support ventilation. This mode provided an automatic selection of initial ventilatory parameters and a continuous adaptation to patient's respiratory activity, guaranteeing that a preset minute ventilation was delivered. Once the patients had recovered sustained spontaneous ventilation, the ventilator was switched manually to pressure support for the terminal part of respiratory weaning followed by extubation. MEASUREMENTS AND MAIN RESULTS: In adaptive support ventilation, all patients could be ventilated satisfactorily except 1; tidal volume was 8.7 +/- 1.4 mL/kg of ideal body weight (mean +/- SD), plateau pressure was 20.3 +/- 3.9 cmH(2)O, and arterial blood gas measurements were satisfactory. One hundred thirty-four patients (86%) were extubated within 6 hours, and intubation time was 3.6 (2.53-4.83) hours (median, [quartiles]). No reintubation because of respiratory failure was required. Adaptive support ventilation was considered easy to use by both the nurses and physicians. CONCLUSIONS: Adaptive support ventilation was used in a group of 155 consecutive patients after fast-track cardiac surgery. This ventilation mode was safe, easy to apply, and allowed rapid extubation in suitable patients. ASV may facilitate postoperative respiratory management.

Aged↗

PubMed2003

Injurious ventilation strategies cause systemic release of IL-6 and MIP-2 in rats in vivo.

In vivo experiments showed no increased production of tumour necrosis factor (TNF) in response to injurious ventilation strategies in otherwise untreated animals. Because interleukin-6 (IL-6) and macrophage inflammatory protein-2 (MIP-2) are more sensitive markers of ventilation-induced cytokine release, serum and bronchoalveolar lavage (BAL) samples were examined for these mediators. Eighty-five adult rats were randomized to three different ventilation strategies. Rats were ventilated with low pressures and low tidal volumes [13/3; peak inspiratory pressure (PIP)/positive end-expiratory pressure (PEEP) in cmH2O], the second group of rats was ventilated with high pressures and low PEEP resulting in high tidal volumes (32/6), and the third group was ventilated with the same high pressures but without PEEP (32/0). Animals were ventilated either for 90 or 240 min, subsequently serum and BAL were collected for analyses on IL-6 and MIP-2 content. Non-ventilated animals served as healthy controls. Ventilation with 32/0 for 90 or 240 min, led to increased serum IL-6 levels. Serum MIP-2 levels were increased by ventilation with 32/6 (90 min) and 32/0 (240 min). Ventilation under any condition, even at 13/3, resulted in elevated MIP-2 levels in the BAL fluid. Even at normal pressures pulmonary MIP-2 levels were increased, suggesting that ventilation may promote pro-inflammatory responses in healthy subjects.

Animals↗

PubMed2005

[Mechanical ventilation on paediatric intensive care units in Czech Republic].

OBJECTIVE: The aims of this study were to evaluate the incidence of mechanically ventilated children in participating units, to find out the demographic data of the patients, to evaluate ventilator settings and to assess the mortality of ventilated children. DESIGN: Prospective observational multicenter study between 1. 2. 2002 and 30. 4. 2002. SETTING: Seven paediatric intensive care units in tertiary hospitals in the Czech Republic. PATIENTS: All children between 1 month and 18 years admitted to the participating paediatric intensive care units who required intubation and mechanical ventilation were enrolled. METHOD: Following parameters were recorded in all patients: demographic data (age, weight, gender), the origin of the admitting diagnosis, severity of illness (Pediatric Risk of Mortality Score - PRISM, Multiorgan System Failure - MOSF, Lung Injury Score - LIS), the origin of respiratory failure, presence of chronic disease and immunosuppression, length of ventilation, length of stay, ventilator setting, the use of unconventional ventilation, outcome (mortality), blood gas analyses and indices (alveoloarterial oxygen difference - AaDO (2), oxygenation index - OI, hypoxemia score - PaO (2)/FiO (2) and ventilation index - VI), deadspace to tidal volume ratio-Vd/Vt and dynamic respiratory system compliance (Cdyn). RESULTS: One hundred and forty four children (42 % girls) were enrolled in total which represent 23 % of all admitted children. The mean age of the patients was 70 months and mean weight was 23 kg. PRISM score and the length of stay were twofold against mean values (11.7 vs. 5.7 and 10.4 vs. 4.8 days respectively). The mean length of ventilation was 117 hours, 66 % of the patients had an extrapulmonary origin of respiratory failure, 19 % of the patients were chronically ill, and 0,7 % had the evidence of immunosuppression. Pressure regulated volume controlled and Biphasic positive airway pressure were the most frequently used ventilator settings. Unconventional ventilation in all was used in 13 % of the patients. Mortality was 3.5 %. CONCLUSION: Children on mechanical ventilation create 23 % of all patients admitted to paediatric intensive care units. The severity of illness and length of stay were twofold against mean values. Mortality rate was 3.5 % and hypoxia was not a cause of death in any patient.

Adolescent↗

PubMed2001

Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation.

BACKGROUND: Positive end-expiratory pressure (PEEP) is commonly applied to the ventilated lung to try to improve oxygenation during one-lung ventilation but is an unreliable therapy and occasionally causes arterial oxygen partial pressure (PaO(2)) to decrease further. The current study examined whether the effects of PEEP on oxygenation depend on the static compliance curve of the lung to which it is applied. METHODS: Forty-two adults undergoing thoracic surgery were studied during stable, open-chest, one-lung ventilation. Arterial blood gases were measured during two-lung ventilation and one-lung ventilation before, during, and after the application of 5 cm H(2)O PEEP to the ventilated lung. The plateau end-expiratory pressure and static compliance curve of the ventilated lung were measured with and without applied PEEP, and the lower inflection point was determined from the compliance curve. RESULTS: Mean (+/- SD) PaO(2) values, with a fraction of inspired oxygen of 1.0, were not different during one-lung ventilation before (192 +/- 91 mmHg), during (190 +/- 90), or after ( 205 +/- 79) the addition of 5 cm H(2)O PEEP. The mean plateau end-expiratory pressure increased from 4.2 to 6.8 cm H(2)O with the application of 5 cm H(2)O PEEP and decreased to 4.5 cm H(2)O when 5 cm H(2)O PEEP was removed. Six patients showed a clinically useful (> 20%) increase in PaO(2) with 5 cm H(2)O PEEP, and nine patients had a greater than 20% decrease in PaO(2). The change in PaO(2) with the application of 5 cm H(2)O PEEP correlated in an inverse fashion with the change in the gradient between the end-expiratory pressure and the pressure at the lower inflection point (r = 0.76). The subgroup of patients with a PaO(2) during two-lung ventilation that was less than the mean (365 mmHg) and an end-expiratory pressure during one-lung ventilation without applied PEEP less than the mean were more likely to have an increase in PaO(2) when 5 cm H(2)O PEEP was applied. CONCLUSIONS: The effects of the application of external 5 cm H(2)O PEEP on oxygenation during one-lung ventilation correspond to individual changes in the relation between the plateau end-expiratory pressure and the inflection point of the static compliance curve. When the application of PEEP causes the end-expiratory pressure to increase from a low level toward the inflection point, oxygenation is likely to improve. Conversely, if the addition of PEEP causes an increased inflation of the ventilated lung that raises the equilibrium end-expiratory pressure beyond the inflection point, oxygenation is likely to deteriorate.

Adult↗

PubMed1993

Synchronous mechanical ventilation of the neonate with respiratory disease.

OBJECTIVES: To assess the importance of synchronization of mechanical ventilation with spontaneous respiratory efforts in mechanically ventilated neonates. The actions of this synchronization on ventilation, oxygenation, and BP variation were assessed. DESIGN: Prospective evaluation using within-subject comparison of asynchronous and synchronous states. SETTING: Neonatal ICU in a large, university-affiliated hospital. PATIENTS: Fourteen neonates requiring mechanical ventilation who were initially asynchronous with the ventilator. INTERVENTION: The ventilator settings were adjusted using the patients' own inspiratory and expiratory timing to create synchronous interaction with the ventilator. MEASUREMENTS AND MAIN RESULTS: Synchrony was assessed using clinical observation combined with inspection of the air flow waveform and computerized analysis of the air flow signal to assess cycle-to-cycle reproducibility, so-called autocorrelation. Synchronous ventilation significantly improved tidal volume (p < .05), minute volume (p < .001), and all indices of the variability of arterial BP (p < .001). Mean airway pressure did not change significantly. No infant developed an airleak syndrome or intraventricular hemorrhage, which have previously been associated with asynchronous ventilation and an unstable BP, respectively. CONCLUSION: Synchronous ventilation can be readily applied to most ventilated neonates. It improves ventilation, and results in a marked reduction in BP variation, which may have implications for reducing the risk of intraventricular hemorrhage.

Blood Pressure↗

PubMed1994

A pressurized injection/suction system for ventilation in the presence of complete airway obstruction.

OBJECTIVE: To describe the design and ventilatory characteristics of a new mode of ventilation (pressurized injection/suction ventilation). DESIGN: Descriptive and analytical laboratory study. SETTING: Laboratory study. SUBJECTS: Simulated lung model and dogs. INTERVENTIONS: We tested the ability to maintain ventilation through a 2.5-mm internal diameter ventilating stylet in the setting of simulated complete airway occlusion. A microprocessor-controlled ventilator mode was used wherein injection of oxygen under high pressure (flow rate 95 L/min) alternates with suction of expired gas (flow rate 18 L/min) through the ventilating stylet. MEASUREMENTS AND MAIN RESULTS: In a lung model, we achieved a maximum minute ventilation of 12.9 L/min. In two dogs, we maintained stable oxygenation (mean PaO2 603 +/- 47 torr [80.4 +/- 6.3 kPa]) and ventilation (mean PaCO2 19 +/- 3 torr [2.5 +/- 0.4 kPa]) for 15 mins at maximum minute ventilation settings. No clinically important deleterious effects on the tracheal mucosa were observed. The ventilator system's safety-abort feature prevented overinflation or excessive deflation of the dogs' lungs in every test of simulated malfunction of the pressure-monitoring mechanism. CONCLUSIONS: Pressurized injection/suction ventilation can maintain adequate gas exchange in an animal model with near-complete airway obstruction. Further work is needed to develop the safety and clinical applications of pressurized injection/suction ventilation in the management of patients with near-complete airway occlusion.

Airway Obstruction↗

PubMed2001

Effort and work of breathing in neonates during assisted patient-triggered ventilation.

OBJECTIVE: This study compares patient-ventilator synchrony, work of breathing and patient effort in neonates during different modes of patient-triggered ventilation. DESIGN: Clinically stable neonates received intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), pressure assist/control ventilation (A/C), and pressure support ventilation (PSV) in a random order for 20 mins. With each mode patient-ventilator synchrony, work of breathing, and patient effort were evaluated. SETTING: Neonatal level III intensive care unit of a university hospital. Measurements and RESULTS: Seven clinically stable neonates (31.4 +/- 2 wks gestation, weighing 1.49 +/- 0.38 kg) were randomly ventilated with the above four modes using a Bird VIP ventilator. Esophageal pressure, airway pressure, and flow were measured using a CP-100 neonatal monitor (Bicore). Data for five consecutive breaths in each mode were analyzed. Patient effort and work of breathing differed significantly among modes of ventilation. The inspiratory pressure time product was least with A/C (0.54 +/- 0.29 cm H(2)O.sec) and increased with PSV (0.60 +/- 0.39 cm H(2)O.sec), SIMV (1.46 +/- 0.55 cm H(2)O.sec), and IMV (2.74 +/- 1.05 cm H(2)O.sec) (p <.05). A similar trend was observed for work of breathing, with work least during A/C (0.07 +/- 0.04 joules per liter [J/L]), followed by PSV (0.17 +/- 0.14 J/L), SIMV (0.33 +/- 0.13 J/L), and IMV (0.41 +/- 0.16 J/L) (p <.05). Marked dyssynchrony between patient-initiated and ventilator-initiated inspiration occurred only during IMV. CONCLUSION: Asynchrony can be avoided by the use of assisted, patient triggered modes of ventilation and, of the available modes, pressure A/C results in the least effort and work of breathing for clinically stable neonates.

Journal Article↗

PubMed2003

Lung-protective ventilation strategies in acute lung injury.

OBJECTIVES: To review the challenges of providing mechanical ventilatory support for respiratory failure while avoiding ventilator-associated lung injury in patients with acute lung injury. To review the results of several randomized clinical trials of lung-protective ventilation strategies using conventional mechanical ventilators. DATA SOURCES: Published reports of clinical trials comparing clinical outcomes of patients with acute lung injury, randomized to mechanical ventilation with either a lung-protective or a control, conventional, standard, or traditional approach. DATA EXTRACTION AND SYNTHESIS: Lung-protective mechanical ventilation strategies are designed to prevent injury from overdistention by using lower tidal volumes and lower inspiratory pressures (volume- and pressure-limited ventilation) or injury from ventilation with atelectasis and alveolar flooding at end-expiration (open-lung ventilation). In one trial, clinical outcomes were better in the study group that received combined volume- and pressure-limited and open-lung strategies compared with the study group that received a conventional approach. Of four trials focusing on volume- and pressure-limited ventilation alone, three did not demonstrate improvements in clinical outcomes, whereas one demonstrated a substantial reduction in mortality and an increase in ventilator-free days. The different results in these four trials may be attributable to differences in tidal volumes between the study groups, chance variation, or differences in the management of respiratory acidosis. CONCLUSIONS: Evidence supports the use of a volume- and pressure-limited approach to mechanical ventilation in patients with acute lung injury. It is not yet clear whether the open-lung approach will further reduce mortality in patients receiving volume- and pressure-limited ventilation support.

Humans↗

PubMed2003

Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center.

OBJECTIVE: To determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders. DESIGN: Patients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-associated pneumonia. Hospital costs were defined by using the hospital cost accounting database. SETTING: The medical and surgical intensive care units at a suburban, tertiary care hospital. PATIENTS: Patients requiring >24 hrs of mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured occurrence of ventilator-associated pneumonia, in-hospital mortality rate, total intensive care unit (ICU) and hospital lengths of stay (LOS), and total hospital cost per patient. Ventilator-associated pneumonia occurred in 127 of 819 patients (15.5%). Compared with uninfected, ventilated patients, patients with ventilator-associated pneumonia had a higher Acute Physiology and Chronic Health Evaluation II score on admission (p <.001) and were more likely to require multiple intubations (p <.001), hemodialysis (p <.001), tracheostomy (p <.001), central venous catheters (p <.001), and corticosteroids (p <.001). Patients with ventilator-associated pneumonia were more likely to be bacteremic during their ICU stay (36 [28%] vs. 22 [3%]; p <.001). Patients with ventilator-associated pneumonia had significantly higher unadjusted ICU LOS (26 vs. 4 days; p <.001), hospital LOS (38 vs. 13 days; p <.001), mortality rate (64 [50%] vs. 237 [34%]; p <.001), and hospital costs (70,568 dollars vs. 21,620 dollars, p <.001). Multiple linear regression, controlling for other factors that may affect costs, estimated the attributable cost of ventilator-associated pneumonia to be 11,897 dollars (95% confidence interval = 5,265 dollars-26,214 dollars; p <.001). CONCLUSIONS: Patients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients. After we adjusted for underlying severity of illness, the attributable cost of ventilator-associated pneumonia was approximately 11,897 dollars.

Adolescent↗

PubMed2004

Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002.

OBJECTIVE: Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality. DESIGN AND SETTING: Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002. PATIENTS: Patients were 9,794 medical and surgical patients >/=18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses). INTERVENTIONS: None. MEASUREMENTS: Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index. MAIN RESULTS: Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were 1.74 billion dollars-22% of all mechanical ventilation patient charges. CONCLUSION: The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically.

Adult↗

PubMed2006

Open lung ventilation does not increase right ventricular outflow impedance: An echo-Doppler study.

OBJECTIVE: Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and elevated positive end-expiratory pressure (PEEP). Elevated PEEP is associated with an increased right ventricular afterload. We investigated the effect of OLC ventilation on right ventricular outflow impedance during inspiration and expiration in patients after cardiac surgery using transesophageal echo-Doppler. DESIGN: A prospective, single-center, crossover, randomized, controlled clinical study. SETTING: Cardiothoracic intensive care unit of a university hospital. PATIENTS: Twenty-eight patients scheduled for elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: In the intensive care unit, each patient was ventilated for approximately 30 mins according to both OLC and conventional ventilation. During OLC ventilation, recruitment maneuvers were applied until PaO2/FiO2 was >375 torr (50 kPa); during conventional ventilation no recruitment maneuvers were performed. MEASUREMENTS AND MAIN RESULTS: Transesophageal echo-Doppler measurements were performed at end-inspiration and end-expiration in a steady-state condition, 20 mins after initiation of a ventilation strategy. Mean acceleration of flow was determined in the long axis of the pulmonary artery in a transverse axis view. During OLC ventilation, a total PEEP of 14 +/- 4 cm H2O was applied vs. 5 cm H2O during conventional ventilation. Mean acceleration during expiration was comparable between groups. During inspiration, OLC ventilation did not cause a decrease of mean acceleration compared with expiration, whereas this did occur during conventional ventilation. CONCLUSIONS: Despite the use of elevated PEEP levels, ventilation according to OLC does not change right ventricular outflow impedance during expiration and decreases right ventricular outflow impedance during inspiration.

Blood Flow Velocity↗

PubMed2003

High tidal volume ventilation induces NOS2 and impairs cAMP- dependent air space fluid clearance.

Tidal volume reduction during mechanical ventilation reduces mortality in patients with acute lung injury and the acute respiratory distress syndrome. To determine the mechanisms underlying the protective effect of low tidal volume ventilation, we studied the time course and reversibility of ventilator-induced changes in permeability and distal air space edema fluid clearance in a rat model of ventilator-induced lung injury. Anesthetized rats were ventilated with a high tidal volume (30 ml/kg) or with a high tidal volume followed by ventilation with a low tidal volume of 6 ml/kg. Endothelial and epithelial protein permeability were significantly increased after high tidal volume ventilation but returned to baseline levels when tidal volume was reduced. The basal distal air space fluid clearance (AFC) rate decreased by 43% (P < 0.05) after 1 h of high tidal volume but returned to the preventilation rate 2 h after tidal volume was reduced. Not all of the effects of high tidal volume ventilation were reversible. The cAMP-dependent AFC rate after 1 h of 30 ml/kg ventilation was significantly reduced and was not restored when tidal volume was reduced. High tidal volume ventilation also increased lung inducible nitric oxide synthase (NOS2) expression and air space total nitrite at 3 h. Inhibition of NOS2 activity preserved cAMP-dependent AFC. Because air space edema fluid inactivates surfactant and reduces ventilated lung volume, the reduction of cAMP-dependent AFC by reactive nitrogen species may be an important mechanism of clinical ventilator-associated lung injury.

Acute Disease↗