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  • 1
    ISSN: 1432-1238
    Keywords: Mechanical ventilation ; Endotracheal tubes ; Obstruction ; Acute respiratory failure
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To evaluate the efficiency of a new device developed to remove obstructions from endotracheal tubes (ETT) in mechanically ventilated patients. Design Open study in mechanically ventilated sedated and paralyzed ICU patients. Setting General ICU and Laboratory of Respiratory Mechanics of the University of Rome “La Sapienza”. Patients 8 consecutive unselected mechanically ventilated, critically ill patients in which a partial obstruction of ETT was suspected on the basis of an increase of the peak inspiratory pressure (〉20%) plus the difficult introduction of a standard suction catheter. Interventions Obstructions to ETT were removed with an experimental “obstruction remover” (OR) Measurements “In vivo” ETT airflow resistance (0.25; 0.5; 0.75; 1l/s) was evaluated before and after use of the OR; the work of breathing necessary to overcome ETT resistance (WOBett) was also evaluated before and after OR use. Results The use of OR significantly reduced in all patients the ETT “in vivo” resistance (From 5.5±2.3 to 2.9±0.5 cmH2O/l/s at 0.25l/s,p〈0.05; from 9±2.4 to 3.8±0.8 cmH2O/l/s at 0.51l/s; from 12.2±3.5 to 5.7±1.2 cmH2O/l/s at 0.75l/s; from 16.9±6 to 9.3±3.8 cmH2O/l/s at 1l/s,p〈0.01 respectively). Also the WOBett was significantly reduced after use of the OR (from 0.66±0.19 to 0.34±0.08 J/l;p〈0.05) Conclusion This experimental device can be safely and successfully used to remove obstructions from the ETT lumen, without suspending mechanical ventilation, reducing the need for rapid ETT substitution in emergency and life-threatening situations.
    Type of Medium: Electronic Resource
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  • 2
    ISSN: 1432-1238
    Keywords: Trauma ; Early bacteremia ; Late bacteremia ; Polymicrobial bacteremia ; Abdominal injury ; Intravascular catheters
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective The aim of this study was to identify risk factors and to describe epidemiological patterns for early—(EOB) and late—onset bacteremias (LOB) after trauma. Design A prospective study conducted on 141 consecutive trauma patients. Setting A general intensive care unit (ICU) of a university hospital. Patients All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severtity of trauma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma. Results Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (x 2=4.1,P=0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99-113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17-10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02-9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23-19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6-8.1). Conclusions Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.
    Type of Medium: Electronic Resource
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  • 3
    ISSN: 1432-1238
    Keywords: Key words Kyphoscoliosis ; Mechanical ventilation ; Respiratory mechanics
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: To evaluate respiratory mechanics in the early phase of decompensation in a group of seven patients with severe kyphoscoliosis (KS) (Cobb angle 〉 90 °) requiring mechanical ventilatory support. Design: Prospective clinical study with a control group. Setting: General intensive care unit at University of Rome “La Sapienza”. Patients: Seven consecutive patients affected by severe KS in the early phase of acute decompensation and a control group of six ASA (American Society of Anesthesiology) 1 subjects who were mechanically ventilated during minor surgery. Measurements and results: Respiratory mechanics were evaluated during constant flow-controlled mechanical ventilation at zero end-expiratory pressure with the end-inspiratory and end-expiratory occlusion technique. In five patients who showed increased ohmic resistance (RRSmin), we evaluated the possibility of reversing this increase with a charge dose of 6 mg/kg doxophylline i. v. In four KS patients, in whom a reliable esophageal pressure was confirmed by a positive occlusion test, we separated respiratory system data into lung and chest wall component. All KS patients showed reduced values of respiratory compliance (CRS) and increased respiratory resistance (RRS). The average basal values of CRS were 36 ± 10 vs 58 ± 8.5 cmH2O in control patients; RRSmax was 20 ± 3.1 vs. 4.5 ± 1.2 cmH2O/l per s; RRSmin 6.2 ± 1.2 vs. 2 ± 0.5 cmH2O/l per s: ΔRRS 14 ± 2.6 cmH2O vs 2.4 ± 0.7 cmH2O/l per s. All KS patients showed low values of intrinsic positive end-expiratory pressure (PEEPi) (1.8 ± 1.5 cmH2O). Separation of lung and chest-wall mechanics, performed only in four patients, showed a reduction in both lung (66.7 ± 7.2 ml/cmH2O) and chest wall values (84 ± 8.2 ml/cmH2O), while both RmaxL and RmaxCW were increased (16.6 ± 2 and 2.8 ± 0.4 cmH2O/l per s, respectively). Infusion of doxophylline did not significantly change respiratory mechanics when evaluated 15, 30, and 45 min after the infusion. Conclusions: During acute decompensation, both lung and chest-wall compliance are severely reduced in KS patients: conversely, and, contrary to that in patients with chronic obstructive pulmonary disease, increases in airway resistance and PEEPi seem to play only a secondary role.
    Type of Medium: Electronic Resource
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  • 4
    ISSN: 1432-1238
    Keywords: Mechanical ventilation ; Endotracheal tube ; Respiratory system resistance ; Airway resistance
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To investigate the role played by the endotracheal tube (ETT) in the correct evaluation of respiratory system mechanics with the end inflation occlusion method during constant flow controlled mechanical ventilation. Setting General ICU, university of Rome “La Sapienza”. Patients 12 consecutive patients undergoing controlled mechanical ventilation. Methods We compared the values of minimal resistance of the respiratory system (i.e. airway resistance) (RRS min) obtained: i) subtracting the theoretical value of ETT resistance from the difference between P max and P1, measured on airway pressure tracings obtained from the distal end of the ETT; ii) directly measuring airway pressure 2 cm below the ETT, thus automatically excluding ETT resistance from the data. Results The values of RRS min obtained by measuring airway pressure below the ETT were significantly lower than those obtained by measuring airway pressure at the distal end of the ETT and subtracting the theoretical ETT resistance (4.5±2.8 versus 2.5±1.6 cm H2O/l/s,p〈0.01). Conclusion When precise measurements of ohmic resistances are required in mechanically ventilated patients, the measurements must be obtained from airways pressure data obtained at tracheal level. The “in vivo” positioning of ETT significantly increases the airflow resistance of the ETT.
    Type of Medium: Electronic Resource
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  • 5
    ISSN: 1432-1238
    Keywords: Key words Trauma ; Early bacteremia ; Late bacteremia ; Polymicrobial bacteremia ; Abdominal injury ; Intravascular catheters
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: The aim of this study was to identify risk factors and to describe epidemiological patterns for early – (EOB) and late – onset bacteremias (LOB) after trauma. Design: A prospective study conducted on 141 consecutive trauma patients. Setting: A general intensive care unit (ICU) of a university hospital. Patients: All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severity of coma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma. Results: Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (ξ2=4.1, P=0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99–113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17–10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02–9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23–19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6–8.1). Conclusions: Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.
    Type of Medium: Electronic Resource
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  • 6
    ISSN: 1432-1238
    Keywords: Muscle relaxants ; Sedation ; Respiratory system mechanics ; Chest wall mechanics ; Mechanical ventilation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To evaluate the separate effects of sedation and paralysis on chest wall and respiratory system mechanics of mechanically ventilated, critically ill patients.Setting: ICU of the University “La Sapienza” Hospital, Rome. Patients and participants 13 critically ill patients were enrolled in this study. All were affected by disease involving both lungs and chest wall mechanics (ARDS in 4 patients, closed chest trauma without flail chest in 4 patients, cardiogenic pulmonary oedema with fluidic overload in 5 patients). Measurements and results Respiratory system and chest wall mechanics were evaluated during constant flow controlled mechanical ventilation in basal conditions (i. e. with the patients under apnoic sedation) and after paralysis with pancuronium bromide. In details, we simultaneously recorded airflow, tracheal pressure, esophageal pressure and tidal volume; with the end-inspiratory and end-expiratory airway occlusion technique we could evaluate respiratory system and chest wall elastance and resistances. Lung mechanics was evaluated by subtracting chest wall from respiratory system data. All data obtained in basal conditions (with the patients sedated with thiopental or propofol) and after muscle paralysis were compared using the Student'st test for paired data. The administration of pancuronium bromide to sedated patients induced a complete muscle paralysis without producing significant modification both to the viscoelastic and to the resistive parameters of chest wall and respiratory system. Conclusions This study demonstrates the lack of additive effects of muscle paralysis in mechanically ventilated, sedated patients. Also in view of the possible side effects of muscle paralysis, our results question the usefulness of generalyzed administration of neuromuscular blocking drugs in mechanically ventilated patients.
    Type of Medium: Electronic Resource
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  • 7
    ISSN: 1432-1238
    Keywords: Key words Acute renal failure ; Trauma ; Rhabdomiolysis ; Mechanical ventilation ; Hemoperitoneum
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma. Design: Prospective observational study. Setting: A general intensive care unit (ICU) of a university hospital. Patients: A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months. Results: Forty-eight (31 %) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p 〈 0.001), higher mortality (p 〈 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS 〉 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) 〉 10 000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score 〈 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure 〉 6 cm H2O, rhabdomyolysis with CPK 〉 10 000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF. Conclusions: The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.
    Type of Medium: Electronic Resource
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  • 8
    ISSN: 1432-1238
    Keywords: ARDS ; Leukotrienes ; Humoral mediators
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Seven patients with the adult respiratory distress syndrome (ARDS) were studied. As a control group we used 6 surgical patients who underwent minor surgical operation (inguinal hernia). For both groups the same sample collection and analysis was used. The presence of leuktorienes (LTs) B4 and C4 and of their isomers 11-trans LTC4 and Δ6-trans-12-epi LTB4 was determined in arterial, mixed venous blood and in bronchoalveolar lavage (BAL) fluid. The samples, analysed by reverse phase high performance liquid chromatography (RP-HPLC), showed a similar chromatographic picture among ARDS patients, while the control group showed no detectable amounts of LTs in BAL or blood. The distribution of these arachidonic acid metabolites in mixed venous blood, arterial blood and BAL seems to suggest pulmonary metabolism and/or inactivation. It is suggested that these mediators act as humoral factors in pathogenesis of the ARDS.
    Type of Medium: Electronic Resource
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  • 9
    ISSN: 1432-1238
    Keywords: Endotracheal tube resistance ; Thoraco-pulmonary mechanics ; Fiber optic catheter ; Mechanical ventilation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: The present study was intended to evaluate the “in vivo” endotracheal (ET) tube resistance and respiratory mechanics in mechanically ventilated patients with respiratory failure by using fiber optic catheters.Design: Two fiber optic catheters, consisting of a thin probe with a pressure transducer on the tip, were used. The first was placed at the proximal side of the ET tube and the second was positioned distally beyond the end. A low compliant air-filled catheter connected to a traditional pressure transducer was placed close to the proximal fiber optic device to compare the pressure values obtained with both systems.Setting: The study was performed in the General Intensive Care Unit of Rome “La Sapienza”, University Hospital.Patients and participants: Seven patients admitted for the management of acute respiratory failure of different etiologies were included in the protocol. All the patients were intubated and mechanically ventilated for a least 48h prior to the investigation.Measurements and results: The endotracheal tube resistance was obtained both by the end-inspiratory occlusion method and measuring pressure proximally and distally to the ET tube. The measurement of respiratory mechanics was obtained proximally and distally to the ET tube. Different flows and tidal volume changes were performed. The results showed that the fiber optic device gives an adequate evaluation of airway pressure and the possibility for an easy detection of obstructions and/or deformations of the ET tube. The area described by inspiratory and expiratory pressure recorded at both sides of the ET tube showed a positive relationship between the surface and flows while no surface changes were shown when the tidal volumes were modified. Thoraco-pulmonary compliance measured proximally and distally to the ET tube gave rise to a small and statistically insignificant differenceConclusion: This study confirms that 48h after the positioning of ET tubes the airflow resistance is significantly higher than might be expected from the “in vitro” data. The presence of the endotracheal tube can interfere with the evaluation of thoraco-pulmonary mechanics, particularly in dynamic conditions. The fiber optic system represents an interesting and simple tool for the evaluation of ET tube resistance and pulmonary mechanics in patients undergoing mechanical ventilation.
    Type of Medium: Electronic Resource
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  • 10
    ISSN: 1432-1238
    Keywords: Auto-PEEP ; COPD ; Pressure support ventilation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract We report a case of hyperinflation induced isorythmic atrio-ventricular dissociation with circulatory failure in a patient with chronic obstructive pulmonary disease. The arrythmia was successfully treated by applying “pressure support ventilation” (PSV: 20 cmH2O) which, by decreasing the respiratory rate and increasing the expiratory time reduced the level of auto-PEEP. In order to explain this result the Authors recorded, in the same patient, the level of auto-PEEP and ΔFRC obtained with Intermittent Positive Pressure Ventilation (IPPV), Intermittent Mandatory Ventilation (IMV) and PSV at the same gas exchange values. PSV showed a dramatic reduction of both these parameters. (Auto-PEEP: IPPV 12 cmH2O, IMV 17 cmH2O, PSV 7 cmH2O).
    Type of Medium: Electronic Resource
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