Determinants of Fi,O2 with oxygen supplementation during noninvasive two-level positive pressure ventilation. (49/494)

To maintain arterial oxygen saturation (Sa,O2) above 90% in patients with acute respiratory failure, oxygen (O2) is often added to the circuit of two-level noninvasive positive pressure ventilation (NPPV). However, the final inspiratory oxygen fraction (Fi,O2) is not known. To clarify this issue, the effect of different inspiratory positive airway pressures (IPAP) of the oxygen tubing connection site and the flow rate of O2, on Fi,O2 was assessed. The effects of the tidal volume (VT) and the respiratory rate on the Fi,O2 were then clarified in a model study. The Fi,O2 varied depending on the point where O2 was added to the circuit. When all other variables were constant, the connection closest to the exhaust port (ventilator side) gave the highest Fi,O2. Increases in IPAP led to decreases in Fi,O2. Finally, Fi,O2 increased with O2 flow, although it was difficult to obtain an Fi,O2 >0.30 unless very high O2 flows were used. Paradoxically, NPPV with low IPAP values and without O2 supplementation led to a Fi,O2 <0.21 at the circuit-patient interface. VT and respiratory rate did not appear to influence Fi,O2. To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L x min(-1).  (+info)

Comparison of ampicillin-sulbactam and imipenem-cilastatin for the treatment of acinetobacter ventilator-associated pneumonia. (50/494)

Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin (Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P>.05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.  (+info)

Optimizing therapeutic approaches in ventilator-associated pneumonia. (51/494)

The world-wide increasing of antimicrobial resistance, face the clinician with the dilemma of treating patients in excess or under-treat patients who need therapy. Early empirical therapy, based on local epidemiological and surveillance data, clinical presentation, timing of onset of pneumonia relative to hospital admission, and administration of prior antibiotics, is often necessary. The first-line therapy in patients with early-onset pneumonia, no risk factor and no prior antibiotics, will be direct to community type organisms, while in patients with late-onset (>5 to 7 days mechanical ventilation) pneumonia, and after prior administration of antibiotics, will be direct to multi-resistant and difficult-to-treat organisms. Risk for development of self-resistance appears higher with imipenem and fluoroquinolones. Obtaining reliable samples to adapt therapy does not improve outcome, but may allow withdrawing of therapy when pneumonia is not confirmed, therefore reducing the overall selective pressure in the ICU environment.  (+info)

Clinical signs and scores for the diagnosis of ventilator-associated pneumonia. (52/494)

The diagnosis of a pneumonia which occurs in critically ill patients undergoing positive pressure mechanical ventilation (ventilator-associated pneumonia, VAP) is often a problem. This is mainly due to the lack of sensitivity and specificity of clinical and radiographic signs of pneumonia in this patient population. Many studies investigated some clinical variables (fever, tracheal aspirates, blood leukocytosis, radiographic criteria): none of these, individually considered, resulted predictive enough to be useful for the bedside diagnosis of VAP. The Clinical Pulmonary Infection Score (CPIS) developed in 1991, based on 6 variables (fever, leukocytosis, tracheal aspirates, oxygenation, radiographic infiltrates, and semi-quantitative cultures of tracheal aspirates with Gram stain) is more sensitive to diagnose VAP. Compared with other associations of clinical variables this one is more flexible and it allows for the signs not to be all present at the same time.  (+info)

Prone position for the prevention of lung infection. (53/494)

Pulmonary infection is frequent in brain injured patients. It has been identified as an independent predictor of unfavorable neurological outcome, calling for attempts of prevention. We recently evaluated intermittent prone positioning for the prevention of ventilator-associated pneumonia (VAP) in comatose brain injured patients, in a randomized study. 25 patients were included in the prone position (PP) group: they were positioned on prone four hours once daily until they could get up to sit in an armchair; 26 patients were included in the supine position (SP) group. The main characteristics of the patients from the two groups were similar at randomization. The primary end-point was the incidence of lung worsening, defined by an increase in the Lung Injury Score by at least one point since the time of randomization. The incidence of lung worsening was lower in the PP group (12%) than in the SP group (50%) (p=0.003). The incidence of VAP was 38.4% in the SP group and 20% in the PP group (p=0.14). There was no serious complication attributable to prone positioning. In conclusion, the beneficial effect of prone positioning for prevention of lung infection in brain injured patients is not well established. However, in those patients, prone positioning is able to avoid the worsening of pulmonary function, especially in oxygenation.  (+info)

Pulmonary infection in the brain injured patient. (54/494)

Incidence of ventilator associated pneumonia (VAP) in brain injury patient ranges from 28 to 40 %. Brain injury may induce immunosuppression explaining why neurotraumapatients are at higher risk of developing early onset pneumonia. However, occurrence of pneumonia in brain injury patient has not been associated to higher mortality. Many methods such as selective digestive decontamination, early administration of antibiotics, continuous subglottic aspiration, improved initial choice and dosage of antibiotic, may be useful to prevent and treat VAP in brain injury.  (+info)

Noninvasive pressure support ventilation. (55/494)

In appropriately selected patients, NPPV decreases intubation rate, improves survival, and is cost-effective. Pressure support ventilation is commonly used successfully for NPPV. An issue with the use of pressure support is the ability of the ventilator to detect the end of inhalation in the presence of leaks or in patients with severe airflow obstruction. A concern with portable pressure ventilators is the potential for rebreathing of carbon dioxide. Despite these issues, pressure support ventilation has been used successfully for noninvasive ventilation in thousands of patients with acute respiratory failure.  (+info)

Infection control in the intensive care unit. The role of the ventilator circuit. (56/494)

Patients are more likely to develop VAP from secretions aspirated past the cuff of the endotracheal tube than by what is breathed through the endotracheal tube. It may be more accurate to use the term "airway-associated pneumonia" rather than "ventilator-associated pneumonia" Several studies have now reported no change in VAP rates when circuits are only changed on an at-needed basis. There is also accumulating evidence that passive humidifiers and closed suction catheters do not need to be changed on a daily basis.  (+info)