Archive for the ‘RS’ Category

Proning – Is it worth the hassle?

Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis

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Extubation to NIPPV

Non-invasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial.

Ornico SR, Lobo SM, Sanches HS, Deberaldini M, Tófoli LT, Vidal AM, Schettino GP, Amato MB, Carvalho CR, Barbas CS. Crit Care. 2013 Mar 4;17(2):R39. (full text available)

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Xtravent

Lower Tidal Volume Strategy (3ml/kg) Combined with Extracorporeal CO2 Removal Versus ‘Conventional’ Protective Ventilation (6 ml/kg) in Severe ARDS (Bein et al)

Intensive Care Med Vol 39, Issue 5, pg 847–856, May 2013

QMC AICU Journal Club, April 2013.

Dr Amit Pancholi 

 

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NMB in Early ARDS.

A fascinating study from the NEJM.

Neuromuscular Blockers in Early ARDS. Papazian, L et al. NEJM. Vol 6, 12, 2010.

This RCT gave a 48 hr infusion of cis-atricurium to early (<24hrs) ARDS patients. It is the first study to show a mortality difference in this condition since ARDSnet a decade ago (although caution is required as it was underpowered). Whilst it is likely that a large proportion of the population included in this study (early, severe ARDS) will already be on NMB to aid ventilation, there has up until now been an assumption that this therapy was a necessary harm (due to the risk of critical illness polyneuropathy and subsequent slow weaning). This study questions that wisdom, showing both a reduction in adjusted mortality at 90 days (although not at 28) and no increase in the risk of CIPN. The results need to be taken with caution, but are certainly interesting and if confirmed may offer an important advance. There is further detailed analysis of the paper in the presentation ‘Atricurium ARDS’ in the blue box. Remember that restrictions on comments have been lifted on Critical Insight, no sign in required – so let us know your opinions.

Steroids for Post Intubation Stridor

A recent Cochrane review of the use of steroids to prevent post extubation stridor in adults and children has been comprehensively reviewed by the McMaster EBM unit for BMJ Evidence. The text below is from their site, which is free access.

BACKGROUND: Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Some clinicians use corticosteroids to prevent or treat post-extubation stridor, but corticosteroids may be associated with adverse effects ranging from hypertension to hyperglycaemia, so a systematic assessment of the efficacy of this therapy is indicated.

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PIRO for Ventilator associated pneumonia

PIRO score for community-acquired pneumonia: A new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia. Lisboa et al. Critical Care Medicine. 37(2):456-462, Feb 2009.

Thanks to Dr. Saule for the presentation on this paper, which can be found in the blue box named PIRO VAP.

Physiology at the extremes

Bubble Trouble : A review of diving physiology. Levitt, D & Millar, I. Post Graduate Med J. 2008; 84 :571-78.

Arterial Blood Gas and oxygen content in climbers on Mount Everest. Grocott, M et al. NEJM. 2009. 360:2;140-49

Something a bit different from the usual critical appraisal. Two recent papers highlighting the potential of studying normal physiology under extreme conditions for increasing our understanding of the physiology of critical illness, and a good read as well! The Caudwell Everest expedition documented paO2 s of 2.7 kPa on the summit, quite incredible. The first paper is a well written summary of diving physiology & pathology which is of interest, especially if you occasionally connect yourself to a ventilation circuit!

Invasive ventilation for COPD patients

Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. Wildman et el. BMJ December 2007.

I think this paper has raised the profile of whether or not to invasively ventilate patients with an exacerbation of COPD. However the paper only includes the prognosis of patients actually admitted to critical care. This means that the pessimisim in these patients was not great enough for them not to be addmitted at all. Whilst a randomised trial including all patients with an exacerbation would be unethical this is a problem with the study.

Dr. Hina Pattani

Non Invasive Ventilation in Acute Cardiogenic Pulmonary Edema

Non-Invasive Ventilation in Acute cardiogenic Pulmonary Edema. Gray, A et al. NEJM, 2008. 359: 142-51. (or here on pubmed)

The “3 interventions in Cardiogenic Pulmonary oedema trial (3CPO)” trail was a multicentre, open, prospective randomised trial. 1069 patients were randomised over 4 years in 23 different centres in the UK. 3 treatment arms, all targeted to achieve sats >92%. 1: Oxygen, 2: CPAP 5-15cmH20 and 3: BiPAP 8-20/4-10.

Previous trials have suggested a reduction in intubation rates and a mortality benefit for CPAP or NIV, but some concerns over an increased MI rate with NIV.

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