Impact of positive end expiratory pressure on cerebral hemodynamic in paediatric patients with post-traumatic brain swelling treated by surgical decompression

<div><p>Introduction</p><p>The objective of our present study is to evaluate the impact of different PEEP levels on cerebral hemodynamic, gas exchanges and respiratory system mechanics in paediatric patients with post-traumatic brain swelling treated with decompressive craniectomy (DC).</p><p>Materials and methods</p><p>A prospective physiologic study was carried out on 14 paediatric patients presenting with severe traumatic brain swelling treated with DC. Transcranial Doppler ultrasonography was performed on the middle cerebral artery bilaterally after DC. After assessment at ZEEP, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), central venous pressure (CVP) and gas exchanges were recorded at PEEP 4 and PEEP 8.</p><p>Results</p><p>From ZEEP to PEEP 8, the compliance of respiratory system indexed to the weight of the patient significantly increased (P = 0.02) without ICP modifications. No significant variation of the MAP, CPP, Vmed, the total resistance of respiratory system and ohmic resistance of the respiratory system indexed to the weight of the patients was observed. CVP significantly increased between ZEEP and PEEP 8 (P = 0.005), and between PEEP 4 and PEEP 8 (P = 0.05).</p><p>Conclusions</p><p>PEEP values up to 8 cmH20 seem to be safe in paediatric patients with a severe post-traumatic brain swelling treated with DC.</p></div

Clinical data.

<p>Data are expressed as median (i.q. range) or number (%). GA: gestational age at the birth; OI: oxygenation index; VI: ventilatory index; RSV: respiratory syncitial virus; BPD: broncho-pulmonary dysplasia.</p

CO₂ driven endotracheal tube cuff control in critically ill patients: A randomized controlled study

<div><p>Background</p><p>To determine the safety and clinical efficacy of an innovative integrated airway system (AnapnoGuard^™ 100 system) that continuously monitors and controls the cuff pressure (P_cuff), while facilitating the aspiration of subglottic secretions (SS).</p><p>Methods</p><p>This was a prospective, single centre, open-label, randomized, controlled feasibility and safety trial. The primary endpoint of the study was the rate of device related adverse events (AE) and serious AE (SAE) as a result of using AnapnoGuard (AG) 100 during mechanical ventilation. Secondary endpoints were: (1) mechanical complications rate (2) ICU staff satisfaction; (3) VAP occurrence; (4) length of mechanical ventilation; (5) length of Intensive Care Unit stay and mortality; (6) volume of evacuated subglottic secretions.</p><p>Sixty patients were randomized to be intubated with the AG endotracheal-tube (ETT) and connected to the AG 100 system allowing P_cuff adjustment and SS aspiration; or with an ETT combined with SS drainage and P_cuff controlled manually.</p><p>Results</p><p>No difference in adverse events rate was identified between the groups. The use of AG system was associated with a significantly higher incidence of P_cuff determinations in the safety range (97.3% vs. 71%; <i>p</i><0.01) and a trend to a greater volume of aspirated SS secretions: (192.0[64–413] ml vs. 150[50–200], <i>p</i> = 0.19 (total)); (57.8[20–88.7] ml vs. 50[18.7–62] ml, <i>p</i> = 0.11 (daily)). No inter-group difference was detected using AG system vs. controls in terms of post-extubation throat pain level (0 [0–2] vs. 0 [0–3]; <i>p</i> = 0.7), hoarseness (42.9% vs. 75%; p = 0.55) and tracheal mucosa oedema (16.7% vs. 10%; <i>p</i> = 0.65).</p><p>Patients enrolled in the AG group had a trend to reduced VAP risk of ventilator-associated pneumonia(VAP) (14.8% vs. 40%; <i>p</i> = 0.06), which were more frequently monomicrobial (25% vs. 70%; <i>p</i> = 0.03).</p><p>No statistically significant difference was observed in duration of mechanical ventilation, ICU stay, and mortality.</p><p>Conclusions</p><p>The use AG 100 system and AG tube in critically ill intubated patients is safe and effective in P_cuff control and SS drainage. Its protective role against VAP needs to be confirmed in a larger randomized trial.</p><p>Trial registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01550978" target="_blank">NCT01550978</a>. Date of registration: February 21, 2012.</p></div

Western blot assay of BAL samples for the two main sPLA2 isotypes that respond differently to varespladib inhibition (sPLA2-IB and sPLA2-IIA).

<p>Illustrative results of four ARDS patients (and human recombinant proteins, as controls) are shown. All patients presents sPLA2-IIA, while some also shown the presence of the isotype –IB. sPLA2: secretory phospholipase A2.</p

sPLA2 activity in the four BAL aliquots treated either with normal saline (basal), or varespladib at 10, at 40 and at 100 µM.

<p>Overall difference in median sPLA2 activity is significant at the Friedman <i>Q</i>-test (see text for details). <i>p</i>-values describe <i>post-hoc</i> comparison: <i>p</i> = 0.013 between basal and varespladib10; <i>p</i> = 0.007 between basal and varespladib40; <i>p</i> = 0.005 between varespladib100 and each other measurement. sPLA2: secretory phospholipase A2.</p

Negative correlation between the reduction of sPLA2 total activity and protein content.

<p>Grey lines represent linear regression line and its 95% confidence interval (rho = 0.906; <i>p</i><0.001; R² = 0.73).</p

Outcome measures in the Anapnoguard 100 and control groups.

<p>Outcome measures in the Anapnoguard 100 and control groups.</p

Subglottic secretions drainage based on rinsing and suctioning.

<p>Subglottic secretions drainage based on rinsing and suctioning.</p

Cumulative rates of patients remaining free of VAP in the AG group and control group, using the Kaplan-Meier method.

<p><i>VAP</i>, Ventilator-Associated Pneumonia; <i>AG</i>, Anapnoguard.</p

Baseline patient characteristics.

<p>Baseline patient characteristics.</p