Noninvasive positive pressure ventilation is required following extubation at the pulmonary infection control window: a prospective observational study.

Clin Respir J. 2013 Nov 27;

Authors: Luo Z, Zhan Q, Wang C

Abstract
INTRODUCTION: Timely extubation and sequential invasive to noninvasive positive pressure ventilation (NPPV) at the pulmonary infection control (PIC) window is beneficial for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, it remains unclear whether patients can breathe independently at the PIC window and if NPPV is indeed necessary after extubation.
OBJECTIVES: To assess whether AECOPD patients can breathe independently at the PIC window and thus whether NPPV is necessary after extubation.
METHODS: We performed a prospective observational study at a university hospital during a 9-month period. We used the spontaneous breathing trial (SBT) to assess whether each patient could breathe independently at the PIC window, then performed extubation. Patients who passed the SBT received venturi oxygen therapy only, whereas those that failed received NPPV. However, if the former showed respiratory distress, they too received NPPV. The primary outcome variables were SBT pass/fail, the demand for NPPV, and rate of reintubation within 72 h following extubation.
RESULTS: In all, 23 patients were enrolled, 15 (65%) of which passed the SBT. Of these, 12 (80%) developed respiratory distress after extubation and required NPPV (1 of whom required reintubation). Of the eight patients that failed, one received reintubation after NPPV. The reintubation rates within 72 h following extubation of SBT-pass (7%) and SBT-fail (13%) patients were comparable.
CONCLUSION: Our results provide experimental evidence that most AECOPD patients can breathe independently at the PIC window, but nonetheless develop respiratory distress and thus require NPPV following extubation.

PMID: 24279808 [PubMed - as supplied by publisher]

Related Articles

Extubation with or without spontaneous breathing trial.

Crit Care Nurse. 2013 Dec;33(6):50-5

Authors: Wang J, Ma Y, Fang Q

Abstract
Purpose- To evaluate whether spontaneous breathing trials (SBTs) are necessary when extubating critical care patients. Methods- A prospective, randomized, double-blind study was performed in adult patients supported by mechanical ventilation for at least 48 hours in the general intensive care unit of a teaching hospital. Patients ready for weaning were randomly assigned to either the SBT group (extubation with an SBT) or the no-SBT group (extubation without an SBT). Patients in the SBT group who tolerated SBT underwent immediate extubation. Patients in the no-SBT group who met the weaning readiness criteria underwent extubation without an SBT. The primary outcome measure was a successful extubation or the ability to maintain spontaneous breathing for 48 hours after extubation. Results- A total of 139 adult patients were enrolled. No significant difference in the demographic, respiratory, and hemodynamic characteristics was indicated between the groups at the end of weaning readiness assessment. Successful extubation was achieved in 56 of 61 patients (91.8%) in the SBT group and 54 of 60 patients (90.0%) in the no-SBT group. In the SBT and no-SBT groups, 5 (8.2%) and 6 (10.0%) patients, respectively, needed reintubation; 7 (11.5%) and 9 (15.0%) patients, respectively, required noninvasive ventilation after extubation. In-hospital mortality did not differ significantly between the groups. Conclusion- Intensive care patients can be extubated successfully without an SBT.

PMID: 24293555 [PubMed - in process]

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Acute respiratory distress syndrome.

Curr Probl Pediatr Adolesc Health Care. 2013 Nov-Dec;43(10):278-84

Authors: Monahan LJ

Abstract
Acute respiratory distress syndrome (ARDS) is commonly associated with severe sepsis. While the criteria for diagnosis have evolved since the first description in 1967, the characteristics of hypoxemia, tachypnea, rapidly progressing acute respiratory failure, and poor lung compliance continue. Scoring systems have been developed in an effort to quantify the severity of lung injury, with the most recent being the Berlin Definition. This system attempts to define acute lung injury (ALI) and ARDS with more precision in terms of timing of disease onset, severity of disease, and chest radiograph findings. The number of reported cases of ALI/ARDS per year is lower in pediatric patients vs. adults; however, mortality rates continue to be high. Sepsis-related ARDS has a generally higher disease severity and poorer recovery period from lung injury with an increased mortality rate. ARDS results from an initial insult (direct and/or indirect) which triggers a series of cell-mediated responses leading to damage to the capillary endothelium, alveolar epithelium, and impaired fluid removal from the alveolar space. There is, however, gradual resolution of hypoxemia, lung function, and radiographic abnormalities in survivors of ARDS. Management of ARDS is mainly supportive with specific mechanical ventilation strategies and goal-directed therapies. Prevention of ventilator-induced lung injury (VILI) has been demonstrated to have a positive impact on outcomes in patients with ARDS.

PMID: 24295609 [PubMed - in process]

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The management of sepsis.

Curr Probl Pediatr Adolesc Health Care. 2013 Nov-Dec;43(10):285-91

Authors: Zawistowski CA

Abstract
Management of sepsis in the pediatric patient is guideline driven. The treatment occurs in two phases, the first hour being the most crucial. Initial treatment consists of timely recognition of shock and interventions aimed at supporting cardiac output and oxygen delivery along with administration of antibiotics. The mainstay of treatment for this phase is fluid resuscitation. For patients in whom this intervention does not reverse the shock medications to support blood pressure should be started and respiratory support may be necessary. Differentiation between warm and cold shock and risk factors for adrenal insufficiency will guide further therapy. Beyond the first hour of treatment patients may require intensive care unit care where invasive monitoring may assist with further treatment options should shock not be reversed in the initial hour of care.

PMID: 24295610 [PubMed - in process]