ABSTRACT While at the Instituto Superiore di Sanità in Rome, Daniel Bovet discovered succinylchol... more ABSTRACT While at the Instituto Superiore di Sanità in Rome, Daniel Bovet discovered succinylcholine to be a depolarizing muscle relaxant. He also synthesized gallamine, the first completely artificial curariform drug to be clinically useful. For his work on synthetic analogs of bioactive amines, he was awarded the 1957 Nobel Prize in Physiology/Medicine. His other important work included contributions to sulfonamide and antihistamine chemistry. His discoveries impacted other works that garnered Nobel Prizes, especially those of Gerhard Domagk, Fritz Lipmann, James W. Black, Gertrude Elion, and George Hitchings.
Assisted ventilation is a highly complex process that requires an intimate interaction between th... more Assisted ventilation is a highly complex process that requires an intimate interaction between the ventilator and the patient. The complexity of this form of ventilation is frequently underappreciated by the bedside clinician. In assisted mechanical ventilation, regardless of the specific mode, the ventilator's gas delivery pattern and the patient's breathing pattern must match near perfectly or asynchrony between the patient and the ventilator occurs. Asynchrony can be categorized into four general types: flow asynchrony; trigger asynchrony; cycle asynchrony; and mode asynchrony. In an article recently published in BMC Anesthesiology, Hodane et al. have demonstrated reduced asynchrony during assisted ventilation with Neurally Adjusted Ventilatory Assist (NAVA) as compared to pressure support ventilation (PSV). These findings add to the growing volume of data indicating that modes of ventilation that provide proportional assistance to ventilation - e.g., NAVA and Proportional Assist Ventilation (PAV) - markedly reduce asynchrony. As it becomes more accepted that the respiratory center of the patient in most circumstances is the most appropriate determinant of ventilatory pattern and as the negative outcome effects of patient-ventilator asynchrony become ever more recognized, we can expect NAVA and PAV to become the preferred modes of assisted ventilation!
Background Although tracheostomy is probably the most common surgical procedure performed on crit... more Background Although tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed.
American journal of respiratory and critical care medicine, 2014
Transfusion of erythrocytes stored for prolonged periods is associated with increased mortality. ... more Transfusion of erythrocytes stored for prolonged periods is associated with increased mortality. Erythrocytes undergo hemolysis during storage and after transfusion. Plasma hemoglobin scavenges endogenous nitric oxide leading to systemic and pulmonary vasoconstriction. We hypothesized that transfusion of autologous blood stored for 40 days would increase the pulmonary artery pressure in volunteers with endothelial dysfunction (impaired endothelial production of nitric oxide). We also tested whether breathing nitric oxide before and during transfusion could prevent the increase of pulmonary artery pressure. Fourteen obese adults with endothelial dysfunction were enrolled in a randomized crossover study of transfusing autologous, leukoreduced blood stored for either 3 or 40 days. Volunteers were transfused with 3-day blood, 40-day blood, and 40-day blood while breathing 80 ppm nitric oxide. The age of volunteers was 41 ± 4 years (mean ± SEM), and their body mass index was 33.4 ± 1.3 k...
Formation of a bacterial biofilm within the endotracheal tube (ETT) after tracheal intubation is ... more Formation of a bacterial biofilm within the endotracheal tube (ETT) after tracheal intubation is rapid and represents a ready source of lung bacterial colonization. The authors investigated bacterial colonization of the ventilator circuit, the ETT, and the lungs when the ETT was coated with silver-sulfadiazine and chlorhexidine in polyurethane, using no bacterial/viral filter attached to the ETT. Sixteen sheep were randomized into two groups. Eight sheep were intubated with a standard ETT (control group), and eight were intubated with a coated ETT (study group). Animals were mechanically ventilated for 24 h. At autopsy, the authors sampled the trachea, bronchi, lobar parenchyma, and ETT for quantitative bacterial cultures. Qualitative bacterial cultures were obtained from the filter, humidifier, inspiratory and expiratory lines, and water trap. ETTs were analyzed with light microscopy, scanning electron microscopy, and laser scanning confocal microscopy. In the control group, all ei...
Low-tidal-volume ventilation reduces mortality in patients with ARDS, but there are often challen... more Low-tidal-volume ventilation reduces mortality in patients with ARDS, but there are often challenges in implementing lung-protective ventilation, such as acidosis from hypercapnia. In a patient with severe ARDS we achieved adequate ventilation with a very low tidal volume (4 mL/kg ideal body weight) by inducing mild hypothermia (body temperature 35-36°C).
Plasma coenzyme Q10 (CoQ10) levels are lower in patients with septic shock (SS) than in healthy c... more Plasma coenzyme Q10 (CoQ10) levels are lower in patients with septic shock (SS) than in healthy controls (HCs). However, CoQ10 status in critically ill patients without SS is unknown. Here, we investigated CoQ10 concentrations in patients with SS and without SS as compared with HCs. We enrolled 36 critically ill patients and 18 HCs. Plasma CoQ10 concentrations were measured, and patients' clinical and demographical data were collected. Plasma CoQ10 concentrations were lower in critically ill patients (0.50±0.36 μg/mL, P<.001), both in patients with SS (0.37±0.25 μg/mL, P=.002) and patients without SS (0.56±0.39, P=.04), as compared with HCs (0.79±0.19). Coenzyme Q10 levels did not differ between patients with SS and patients without SS (P=.13). In critically ill patients, CoQ10 levels inversely correlated with age (r=-0.40, P=.015) and did not correlate with partial pressure of oxygen in the arterial blood/fraction of inspired oxygen, Simplified Acute Physiology Score II, Systemic Organ Failure Assessment score, or mortality. Lower CoQ10 levels were associated with lower activities of daily living score after discharge (P=.005), independent of age. Decreased plasma CoQ10 levels are not specific to patients with SS, but rather observed in a broad range of critically ill patients. In critically ill patients, CoQ10 insufficiency may be associated with various conditions; age may be a risk factor.
Journal of Cardiothoracic and Vascular Anesthesia, 2008
ABSTRACT HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) is a syndrome of thrombocytopenia caused by circu... more ABSTRACT HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) is a syndrome of thrombocytopenia caused by circulating Ig antibodies ("HIT antibodies") that bind to heparin platelet factor 4 cornplexes.(1) HIT with thrombosis (HITT) is HIT with the clinical syndrome of arterial or venous thrombosis because of platelet activation. The frequency of development of HIT antibodies depends on the type of heparin exposure (higher with unfractionated hepanin [UFH] compared with low-molecular-weight heparin [LMWH]) and the patient population (surgical patients higher than medical patients). Cardiac surgical patients who are exposed to UFH perioperatively have a 50% incidence of detectable HIT antibodies.' In orthopedic surgical patients, the incidence is 15% with exposure to UFH but only 8% with exposure to LMWH.(1) Not all patients who develop HIT antibodies will become thrombocytopenic. Clinical HIT with thrombocytopenia below 100,0001/mu L is uncommon, and thrombosis (HITT) is rare (0%-5% of patients).(2-5) Thrombocytopenia develops generally within 4 to 15 days of exposure to heparin but occasionally call Occur within hours (rapid-onset HIT) because of the presence of circulating HIT antibodies formed after a recent exposure.(6-8) Of 73 patients identified to have had rapid-onset HIT over a period of 15 years, most had received heparin (all UFH) within the previous 3 weeks and all within the previous 100 days.(6) The authors describe a case of fatal rapid-onset HIT in a patient of previously unknown HIT status who had received UFH more than I year and LMWH 8 months before the current admission.
To assess the long-term benefit from antibacterial coatings of the tracheal tube (ETT), and to ke... more To assess the long-term benefit from antibacterial coatings of the tracheal tube (ETT), and to keep clean the lumen of the ETT. Experimental animal study. USA National Institutes of Health. Twelve sheep. Twelve ETTs were internally dip-coated with a silver-sulfadiazine in polyurethane. We developed a concentric inflatable silicone rubber "razor", the Mucus Shaver (MS), to shave the ETT lumen free of mucus. In a single pass, we cleaned all mucus from the internal surface of the ETT. Five intubated sheep were mechanically ventilated for 72 h. The ETT was suctioned every 6 h. Six sheep were intubated and mechanically ventilated for 72 h. The ETT was suctioned and cleaned with the MS every 6 h. An additional sheep was intubated and mechanically ventilated for 168 h. Bacteriologic studies and scanning electron microscopy were performed to assess bacterial colonization and thickness of secretions on the internal surface of the ETT. In the control group, the ETT was always heavily colonized: median debris thickness was 380 microm, range 270-550 microm. In the study group, there was no colonization and no secretions in the ETT, except for three ETT that were colonized solely at the very tip. Silver-based coating of ETT cleaned with the MS every 6 h significantly reduces accumulation of mucus/secretion and bacterial growth within the ETT following 72 h of mechanical ventilation.
ABSTRACT Pseudomonas aeruginosa (P. aeruginosa) is a Gram-negative, aerobic, rod-shaped and polar... more ABSTRACT Pseudomonas aeruginosa (P. aeruginosa) is a Gram-negative, aerobic, rod-shaped and polar-flagella bacterium with unipolar motility, and an opportunistic pathogen responsible for ventilator-acquired pneumonia (VAP). VAP due to P. aeruginosa is usually multidrug-resistant and associated with severe infection and increased mortality. The large genome and the high level of gene regulation may explain part of the significant virulence and of the prominent adaptability to different environments of this pathogen. In this review, we discussed the potential relationship between some of the virulent factors of P. aeruginosa and outcome of patient with VAP.
ABSTRACT Endotracheal tubes (ETT) of intubated patients are constantly challenged with abundant b... more ABSTRACT Endotracheal tubes (ETT) of intubated patients are constantly challenged with abundant bacteria-laden secretions. These bacteria may rapidly form a well-organized structure, referred to as biofilm, on the inner surface of the ETT. Secretions become very tenacious and are difficult to clear. However, bacteria and secretions can detach spontaneously or become dislodged by suction catheters and enter the lungs, providing a source of infection. Recently, several strategies have been developed to prevent accumulation of mucus and bacterial colonization of the respiratory circuit. In this review, we summarize published studies on antimicrobial ETT-coated and clearance devices. Numerous antimicrobial-impregnated ETTs have been designed with bactericidal/static properties to prevent adhesion of bacteria on ETT surfaces. Several in vitro experiments and animal-studies have shown success in the prevention of bacterial colonization through the use of these specialized ETTs. At present, only two ETT coatings, silver-hydrogel and silver-sulfadiazine in polyurethane, have been tested in clinical trials. Both coatings have been shown to prevent/lower bacterial colonization of the ETT, while only the silver-hydrogel coating decreased bacterial colonization of lungs in a large multicenter study. Another innovative approach is to reduce contaminated-secretions in the ETT-lumen with novel medical devices designed to retrieve accumulated-mucus from the ETT. The mucus shaver and the mucus slurper are two devices intended to reduce loaded-bacteria secretions from within the ETT. While experimental and preliminary clinical trials are promising, there are no large clinical trials showing outcome benefits.
The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ven... more The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ventilator-associated pneumonia (VAP) during mechanical ventilation. A number of modifications to the ETT are available, aimed at reducing the incidence of VAP. We review here available systems and devices, and clinical data regarding their efficacy. Three main modifications of ETTs have been developed: coating with antimicrobials, adding a suction channel for the removal of oro-pharyngeal secretions, and modifying the design of the cuff. Each of these interventions has been shown to limit bacterial colonization of the distal airways and to decrease the incidence of VAP. Data on their ultimate effect on related clinical outcomes are still lacking. Modifications of ETTs aimed at decreasing the onset of VAP show promising results. However, the lack of a significant effect on outcomes prompts us to use caution before recommending their widespread use.
I-cysteine, NH 2 -CH(CO 2 H)-CH 2 -SH, is present in most proteins and is one of the sulfur-conta... more I-cysteine, NH 2 -CH(CO 2 H)-CH 2 -SH, is present in most proteins and is one of the sulfur-containing amino acids. Its oxidized dimer, cystine, was the first amino acid to be isolated and is so-named because it was found in urinary calculi in 1810. Cysteine is a component of glutathione, a ...
To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to a... more To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to an acute care respiratory unit after critical illness. Prospective, observational study of 210 consecutive patients admitted to a respiratory unit of an acute, tertiary care university hospital, who had an acute critical illness with respiratory failure. The study was powered to develop multivariate regression models to investigate the relationship between patient characteristics and a) liberation from mechanical ventilation and b) survival. None. The median time to liberation from mechanical ventilation after respiratory unit admission was 14 days (interquartile range, 6-51). A total of 146 patients (69%) were off mechanical ventilation at 6 months, and 123 patients (61%) were alive at 1 yr. Patients who did not come off mechanical ventilation in the respiratory unit were seven times more likely to die within a year than those who did (odds ratio, 6.55; 95% confidence intervals, 4.04-10.63; p < .001). At least 75% of deaths occurred by consensual withdrawal of life support. Patient activity of daily living scores (0-100 scale) increased progressively from hospital discharge (24 +/- 6) through 3 (54 +/- 21) and 6 months (64 +/- 22) (p < .001). The median cost of hospitalization for all study patients was $149,624 (interquartile range, $102,540-225,843). The majority of patients requiring prolonged mechanical ventilation in a respiratory unit after acute critical illness are liberated from mechanical ventilation, survive, and have a steady improvement in the activity of daily living during the first 6 months after discharge. However, a substantial fraction of these patients does not wean from mechanical ventilation and dies from consensual withdrawal of life support after a prolonged and costly hospital stay.
ABSTRACT While at the Instituto Superiore di Sanità in Rome, Daniel Bovet discovered succinylchol... more ABSTRACT While at the Instituto Superiore di Sanità in Rome, Daniel Bovet discovered succinylcholine to be a depolarizing muscle relaxant. He also synthesized gallamine, the first completely artificial curariform drug to be clinically useful. For his work on synthetic analogs of bioactive amines, he was awarded the 1957 Nobel Prize in Physiology/Medicine. His other important work included contributions to sulfonamide and antihistamine chemistry. His discoveries impacted other works that garnered Nobel Prizes, especially those of Gerhard Domagk, Fritz Lipmann, James W. Black, Gertrude Elion, and George Hitchings.
Assisted ventilation is a highly complex process that requires an intimate interaction between th... more Assisted ventilation is a highly complex process that requires an intimate interaction between the ventilator and the patient. The complexity of this form of ventilation is frequently underappreciated by the bedside clinician. In assisted mechanical ventilation, regardless of the specific mode, the ventilator's gas delivery pattern and the patient's breathing pattern must match near perfectly or asynchrony between the patient and the ventilator occurs. Asynchrony can be categorized into four general types: flow asynchrony; trigger asynchrony; cycle asynchrony; and mode asynchrony. In an article recently published in BMC Anesthesiology, Hodane et al. have demonstrated reduced asynchrony during assisted ventilation with Neurally Adjusted Ventilatory Assist (NAVA) as compared to pressure support ventilation (PSV). These findings add to the growing volume of data indicating that modes of ventilation that provide proportional assistance to ventilation - e.g., NAVA and Proportional Assist Ventilation (PAV) - markedly reduce asynchrony. As it becomes more accepted that the respiratory center of the patient in most circumstances is the most appropriate determinant of ventilatory pattern and as the negative outcome effects of patient-ventilator asynchrony become ever more recognized, we can expect NAVA and PAV to become the preferred modes of assisted ventilation!
Background Although tracheostomy is probably the most common surgical procedure performed on crit... more Background Although tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed.
American journal of respiratory and critical care medicine, 2014
Transfusion of erythrocytes stored for prolonged periods is associated with increased mortality. ... more Transfusion of erythrocytes stored for prolonged periods is associated with increased mortality. Erythrocytes undergo hemolysis during storage and after transfusion. Plasma hemoglobin scavenges endogenous nitric oxide leading to systemic and pulmonary vasoconstriction. We hypothesized that transfusion of autologous blood stored for 40 days would increase the pulmonary artery pressure in volunteers with endothelial dysfunction (impaired endothelial production of nitric oxide). We also tested whether breathing nitric oxide before and during transfusion could prevent the increase of pulmonary artery pressure. Fourteen obese adults with endothelial dysfunction were enrolled in a randomized crossover study of transfusing autologous, leukoreduced blood stored for either 3 or 40 days. Volunteers were transfused with 3-day blood, 40-day blood, and 40-day blood while breathing 80 ppm nitric oxide. The age of volunteers was 41 ± 4 years (mean ± SEM), and their body mass index was 33.4 ± 1.3 k...
Formation of a bacterial biofilm within the endotracheal tube (ETT) after tracheal intubation is ... more Formation of a bacterial biofilm within the endotracheal tube (ETT) after tracheal intubation is rapid and represents a ready source of lung bacterial colonization. The authors investigated bacterial colonization of the ventilator circuit, the ETT, and the lungs when the ETT was coated with silver-sulfadiazine and chlorhexidine in polyurethane, using no bacterial/viral filter attached to the ETT. Sixteen sheep were randomized into two groups. Eight sheep were intubated with a standard ETT (control group), and eight were intubated with a coated ETT (study group). Animals were mechanically ventilated for 24 h. At autopsy, the authors sampled the trachea, bronchi, lobar parenchyma, and ETT for quantitative bacterial cultures. Qualitative bacterial cultures were obtained from the filter, humidifier, inspiratory and expiratory lines, and water trap. ETTs were analyzed with light microscopy, scanning electron microscopy, and laser scanning confocal microscopy. In the control group, all ei...
Low-tidal-volume ventilation reduces mortality in patients with ARDS, but there are often challen... more Low-tidal-volume ventilation reduces mortality in patients with ARDS, but there are often challenges in implementing lung-protective ventilation, such as acidosis from hypercapnia. In a patient with severe ARDS we achieved adequate ventilation with a very low tidal volume (4 mL/kg ideal body weight) by inducing mild hypothermia (body temperature 35-36°C).
Plasma coenzyme Q10 (CoQ10) levels are lower in patients with septic shock (SS) than in healthy c... more Plasma coenzyme Q10 (CoQ10) levels are lower in patients with septic shock (SS) than in healthy controls (HCs). However, CoQ10 status in critically ill patients without SS is unknown. Here, we investigated CoQ10 concentrations in patients with SS and without SS as compared with HCs. We enrolled 36 critically ill patients and 18 HCs. Plasma CoQ10 concentrations were measured, and patients' clinical and demographical data were collected. Plasma CoQ10 concentrations were lower in critically ill patients (0.50±0.36 μg/mL, P<.001), both in patients with SS (0.37±0.25 μg/mL, P=.002) and patients without SS (0.56±0.39, P=.04), as compared with HCs (0.79±0.19). Coenzyme Q10 levels did not differ between patients with SS and patients without SS (P=.13). In critically ill patients, CoQ10 levels inversely correlated with age (r=-0.40, P=.015) and did not correlate with partial pressure of oxygen in the arterial blood/fraction of inspired oxygen, Simplified Acute Physiology Score II, Systemic Organ Failure Assessment score, or mortality. Lower CoQ10 levels were associated with lower activities of daily living score after discharge (P=.005), independent of age. Decreased plasma CoQ10 levels are not specific to patients with SS, but rather observed in a broad range of critically ill patients. In critically ill patients, CoQ10 insufficiency may be associated with various conditions; age may be a risk factor.
Journal of Cardiothoracic and Vascular Anesthesia, 2008
ABSTRACT HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) is a syndrome of thrombocytopenia caused by circu... more ABSTRACT HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) is a syndrome of thrombocytopenia caused by circulating Ig antibodies ("HIT antibodies") that bind to heparin platelet factor 4 cornplexes.(1) HIT with thrombosis (HITT) is HIT with the clinical syndrome of arterial or venous thrombosis because of platelet activation. The frequency of development of HIT antibodies depends on the type of heparin exposure (higher with unfractionated hepanin [UFH] compared with low-molecular-weight heparin [LMWH]) and the patient population (surgical patients higher than medical patients). Cardiac surgical patients who are exposed to UFH perioperatively have a 50% incidence of detectable HIT antibodies.' In orthopedic surgical patients, the incidence is 15% with exposure to UFH but only 8% with exposure to LMWH.(1) Not all patients who develop HIT antibodies will become thrombocytopenic. Clinical HIT with thrombocytopenia below 100,0001/mu L is uncommon, and thrombosis (HITT) is rare (0%-5% of patients).(2-5) Thrombocytopenia develops generally within 4 to 15 days of exposure to heparin but occasionally call Occur within hours (rapid-onset HIT) because of the presence of circulating HIT antibodies formed after a recent exposure.(6-8) Of 73 patients identified to have had rapid-onset HIT over a period of 15 years, most had received heparin (all UFH) within the previous 3 weeks and all within the previous 100 days.(6) The authors describe a case of fatal rapid-onset HIT in a patient of previously unknown HIT status who had received UFH more than I year and LMWH 8 months before the current admission.
To assess the long-term benefit from antibacterial coatings of the tracheal tube (ETT), and to ke... more To assess the long-term benefit from antibacterial coatings of the tracheal tube (ETT), and to keep clean the lumen of the ETT. Experimental animal study. USA National Institutes of Health. Twelve sheep. Twelve ETTs were internally dip-coated with a silver-sulfadiazine in polyurethane. We developed a concentric inflatable silicone rubber "razor", the Mucus Shaver (MS), to shave the ETT lumen free of mucus. In a single pass, we cleaned all mucus from the internal surface of the ETT. Five intubated sheep were mechanically ventilated for 72 h. The ETT was suctioned every 6 h. Six sheep were intubated and mechanically ventilated for 72 h. The ETT was suctioned and cleaned with the MS every 6 h. An additional sheep was intubated and mechanically ventilated for 168 h. Bacteriologic studies and scanning electron microscopy were performed to assess bacterial colonization and thickness of secretions on the internal surface of the ETT. In the control group, the ETT was always heavily colonized: median debris thickness was 380 microm, range 270-550 microm. In the study group, there was no colonization and no secretions in the ETT, except for three ETT that were colonized solely at the very tip. Silver-based coating of ETT cleaned with the MS every 6 h significantly reduces accumulation of mucus/secretion and bacterial growth within the ETT following 72 h of mechanical ventilation.
ABSTRACT Pseudomonas aeruginosa (P. aeruginosa) is a Gram-negative, aerobic, rod-shaped and polar... more ABSTRACT Pseudomonas aeruginosa (P. aeruginosa) is a Gram-negative, aerobic, rod-shaped and polar-flagella bacterium with unipolar motility, and an opportunistic pathogen responsible for ventilator-acquired pneumonia (VAP). VAP due to P. aeruginosa is usually multidrug-resistant and associated with severe infection and increased mortality. The large genome and the high level of gene regulation may explain part of the significant virulence and of the prominent adaptability to different environments of this pathogen. In this review, we discussed the potential relationship between some of the virulent factors of P. aeruginosa and outcome of patient with VAP.
ABSTRACT Endotracheal tubes (ETT) of intubated patients are constantly challenged with abundant b... more ABSTRACT Endotracheal tubes (ETT) of intubated patients are constantly challenged with abundant bacteria-laden secretions. These bacteria may rapidly form a well-organized structure, referred to as biofilm, on the inner surface of the ETT. Secretions become very tenacious and are difficult to clear. However, bacteria and secretions can detach spontaneously or become dislodged by suction catheters and enter the lungs, providing a source of infection. Recently, several strategies have been developed to prevent accumulation of mucus and bacterial colonization of the respiratory circuit. In this review, we summarize published studies on antimicrobial ETT-coated and clearance devices. Numerous antimicrobial-impregnated ETTs have been designed with bactericidal/static properties to prevent adhesion of bacteria on ETT surfaces. Several in vitro experiments and animal-studies have shown success in the prevention of bacterial colonization through the use of these specialized ETTs. At present, only two ETT coatings, silver-hydrogel and silver-sulfadiazine in polyurethane, have been tested in clinical trials. Both coatings have been shown to prevent/lower bacterial colonization of the ETT, while only the silver-hydrogel coating decreased bacterial colonization of lungs in a large multicenter study. Another innovative approach is to reduce contaminated-secretions in the ETT-lumen with novel medical devices designed to retrieve accumulated-mucus from the ETT. The mucus shaver and the mucus slurper are two devices intended to reduce loaded-bacteria secretions from within the ETT. While experimental and preliminary clinical trials are promising, there are no large clinical trials showing outcome benefits.
The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ven... more The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ventilator-associated pneumonia (VAP) during mechanical ventilation. A number of modifications to the ETT are available, aimed at reducing the incidence of VAP. We review here available systems and devices, and clinical data regarding their efficacy. Three main modifications of ETTs have been developed: coating with antimicrobials, adding a suction channel for the removal of oro-pharyngeal secretions, and modifying the design of the cuff. Each of these interventions has been shown to limit bacterial colonization of the distal airways and to decrease the incidence of VAP. Data on their ultimate effect on related clinical outcomes are still lacking. Modifications of ETTs aimed at decreasing the onset of VAP show promising results. However, the lack of a significant effect on outcomes prompts us to use caution before recommending their widespread use.
I-cysteine, NH 2 -CH(CO 2 H)-CH 2 -SH, is present in most proteins and is one of the sulfur-conta... more I-cysteine, NH 2 -CH(CO 2 H)-CH 2 -SH, is present in most proteins and is one of the sulfur-containing amino acids. Its oxidized dimer, cystine, was the first amino acid to be isolated and is so-named because it was found in urinary calculi in 1810. Cysteine is a component of glutathione, a ...
To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to a... more To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to an acute care respiratory unit after critical illness. Prospective, observational study of 210 consecutive patients admitted to a respiratory unit of an acute, tertiary care university hospital, who had an acute critical illness with respiratory failure. The study was powered to develop multivariate regression models to investigate the relationship between patient characteristics and a) liberation from mechanical ventilation and b) survival. None. The median time to liberation from mechanical ventilation after respiratory unit admission was 14 days (interquartile range, 6-51). A total of 146 patients (69%) were off mechanical ventilation at 6 months, and 123 patients (61%) were alive at 1 yr. Patients who did not come off mechanical ventilation in the respiratory unit were seven times more likely to die within a year than those who did (odds ratio, 6.55; 95% confidence intervals, 4.04-10.63; p < .001). At least 75% of deaths occurred by consensual withdrawal of life support. Patient activity of daily living scores (0-100 scale) increased progressively from hospital discharge (24 +/- 6) through 3 (54 +/- 21) and 6 months (64 +/- 22) (p < .001). The median cost of hospitalization for all study patients was $149,624 (interquartile range, $102,540-225,843). The majority of patients requiring prolonged mechanical ventilation in a respiratory unit after acute critical illness are liberated from mechanical ventilation, survive, and have a steady improvement in the activity of daily living during the first 6 months after discharge. However, a substantial fraction of these patients does not wean from mechanical ventilation and dies from consensual withdrawal of life support after a prolonged and costly hospital stay.
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