Mechanical ventilation in patients with acute brain injury

El objetivo de este trabajo es describir aspectos relacionados con el manejo de la vía aérea superior, de la ventilación mecánica y sus consecuencias, haciendo especial énfasis en aquellos casos en que la lesión cerebral aguda se encuentra acompañada de insuficiencia respiratoria aguda (IRA)

Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management

BACKGROUND: Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation. METHODS: We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model). RESULTS: Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively). CONCLUSIONS: Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov

Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation

19A new classification of patients based on the duration of liberation of mechanical ventilation has been proposed.To analyze outcomes based on the new weaning classification in a cohort of mechanically ventilated patients.Secondary analysis included 2,714 patients who were weaned and underwent scheduled extubation from a cohort of 4,968 adult patients mechanically ventilated for more than 12 hours.Patients were classified according to a new weaning classification: 1,502 patients (55\%) as simple weaning,1,058 patients (39\%) as difficult weaning, and 154 (6\%) as prolonged weaning.Variables associated with prolonged weaning(.7d)were: severity at admission (odds ratio [OR] per unit of Simplified Acute Physiology Score II, 1.01; 95\% confidence interval [CI], 1.001–1.02), duration of mechanical ventilation before first attempt of weaning (OR per day, 1.10; 95\% CI, 1.06–1.13), chronic pulmonary disease other than chronic obstructive pulmonary disease (OR,13.23; 95\% CI, 3.44–51.05), pneumonia as the reason to start mechanical ventilation (OR, 1.82; 95\% CI, 1.07–3.08), and level of positive end-expiratory pressure applied before weaning (OR per unit,1.09; 95\% CI, 1.04–1.14). The prolonged weaning group had a nonsignificant trend toward a higher rate of reintubation (P ¼ 0.08),tracheostomy (P ¼ 0.15), and significantly longer length of stay and higher mortality in the intensive care unit (OR for death, 1.97;95\%CI, 1.17–3.31). The adjusted probability of death remained constant until Day 7, at which point it increased to 12.1\%.noneO. Peñuelas; F. Frutos-Vivar; C. Fernández; A. Anzueto; S. K. Epstein; C. Apezteguía; M. González; N. Nin; K. Raymondos; V. Tomicic; P. Desmery; Y. Arabi; P. Pelosi; M. Kuiper; M. Jibaja; D. Matamis; N. D. Ferguson; A. Esteban; P. SevergniniO., Peñuelas; F., Frutos Vivar; C., Fernández; A., Anzueto; S. K., Epstein; C., Apezteguía; M., González; N., Nin; K., Raymondos; V., Tomicic; P., Desmery; Y., Arabi; P., Pelosi; M., Kuiper; M., Jibaja; D., Matamis; N. D., Ferguson; A., Esteban; Severgnini, Paol