Background In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. Methods We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection poin...

https://www.nejm.org/doi/pdf/10.1056/NEJM199802053380602

Effect of a Protective-Ventilation Strategy on Mortality in the Acute Respiratory Distress Syndrome

Nosocomial pneumonia in ventilated patients: A cohort study evaluating attributable mortality and hospital stay

Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients

To determine risk factors for ventilator-associated pneumonia (VAP) caused by potentially drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and/or Stenotrophomonas maltophilia, 135 consecutive episodes of VAP observed in a single ICU over a 25-mo period were prospectively studied. For all patients, VAP was diagnosed based on results of bronchoscopic protected specimen brush (> or = 10(3) cfu/ml) and bronchoalveolar lavage (> or = 10(4) cfu/ml) specimens. Seventy-seven episodes were caused by "potentially resistant" bacteria and 58 episodes were caused by "other" organisms. According to logistic regression analysis, three variables among potential factors remained significant: duration of mechanical ventilation (MV) > or = 7 d (odds ratio [OR] = 6.0), prior antibiotic use (OR = 13.5), and prior use of broad-spectrum drugs (third-generation cephalosporin, fluoroquinolone, and/or imipenem) (OR = 4.1). Distribution of the 245 causative bacteria was analyzed according to four groups defined by prior duration of MV ( or = 7 d) and prior use or lack of use (within 15 d) of antibiotics. Although 22 episodes of early-onset VAP in patients receiving no prior antibiotics were caused by antibiotic-susceptible bacteria, 84 episodes of late-onset VAP in patients receiving prior antibiotics were mainly caused by potentially resistant bacteria. Differences in the potential efficacies (ranging from 100% to 11%) against microorganisms of 15 antimicrobial regimens were studied according to classification into these four groups. These findings may provide a more rational basis for selecting the initial therapy of patients suspected of having VAP.

Ventilator-associated pneumonia caused by potentially drug-resistant bacteria

Background: Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate. Objective: To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition. Design: Multicenter, randomized, uncontrolled trial. Setting: 31 intensive care units in France. Patients: 413 patients suspected of having ventilator-associated pneumonia. Intervention: The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive (clinical) management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines. Measurements: Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days. Results: Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, -9.6 percentage points [95% Cl, -17.4 to -1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1 ± 4.0 and 7.0 ± 4.3; P = 0.033) and day 7 (4.9 ± 4.0 and 5.8 ± 4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0 ± 5.1 and 2.2 ± 3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5 ± 9.0 compared with 7.5 ± 7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01). Conclusions: Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.

Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia : A randomized trial

https://www.amjmed.com/article/0002-9343(74)90440-9/pdf

Complications of assisted ventilation: A prospective study of 354 consecutive episodes

Ten patients with the Pickwickian syndrome, characterized by obesity, hypoxemia, hypercapnia, polycythemia, and cor pulmonale, underwent long-term treatment as outpatients with medroxyprogesterone acetate. Although there was no significant weight change in the group, PaO2 rose 12.6 +/- 2.7 mm Hg (SEM) from 49 +/- 2.6 mm Hg to 62 +/- 2.3 mm Hg (P less than 0.001), while PaCO2 fell 13 +/- 2.6 mm Hg from 51 +/- 1.9 mm Hg to 38 +/- 1.2 mm Hg (P less than 0.001). Hematocrit fell from 56 +/- 2.5% to 50 +/- 1.2%, a mean fall of 6% (P less than 0.01), during medroxyprogesterone acetate therapy. In the 2 patients who had cardiac catheterization before and during medroxyprogesterone acetate therapy, mean pulmonary arterial pressure fell 13 and 19 mm Hg. There were no recurrences of cor pulmonale during treatment. These effects on arterial blood gas values and clinical state were sustained during therapy. On withdrawal of medroxyprogesterone acetate during 1-month period, arterial oxygen and carbon dioxide tensions deteriorated to their previous pretreatment values. Reinstitution of medroxyprogesterone acetate caused improvement in both the oxygen and carbon dioxide tensions. We conclude that sublingual medroxyprogesterone acetate therapy is useful in the management of the Pickwickian syndrome.

Progesterone for Outpatient Treatment of Pickwickian Syndrome

Primary cutaneous inoculation drug-resistant tuberculosis

Nasal Necrosis: A Complication of Nasotracheal Intubation

Two cases of nasal necrosis in association with nasotracheal intubation are presented. This complication is probably preventable if the site of the contact between tube and nose is inspected twice daily, and the tube removed at the first sign of severe erythema, and secondly by preventing sharp angulation between tube and nose.

David J. Pierson

Papers

Complications of assisted ventilation: A prospective study of 354 consecutive episodes

Progesterone for Outpatient Treatment of Pickwickian Syndrome

Primary cutaneous inoculation drug-resistant tuberculosis

Nasal Necrosis: A Complication of Nasotracheal Intubation

Nasal necrosis; a complication of nasotracheal intubation