High-frequency oscillation and tracheal gas insufflation in patients with severe acute respiratory distress syndrome and traumatic brain injury: an interventional physiological study

In acute respiratory distress syndrome (ARDS), combined high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) improves gas exchange compared with conventional mechanical ventilation (CMV). We evaluated the effect of HFO-TGI on PaO2/fractional inspired O2 (FiO2) and PaCO2, systemic hemodynamics, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) in patients with traumatic brain injury (TBI) and concurrent severe ARDS

The effect of high frequency oscillatory ventilation combined with tracheal gas insufflation on extravascular lung water in patients with acute respiratory distress syndrome: a randomized, crossover, physiological study.

Purpose: High frequency oscillation combined with tracheal gas insufflation (HFO-TGI) improves oxygenation in patients with Acute Respiratory Distress Syndrome (ARDS). There is limited physiologic data regarding the effects of HFO-TGI on hemodynamics and pulmonary edema during ARDS. The aim of this study was to investigate the effect of HFO-TGI on extravascular lung water (EVLW). Materials and Methods: We conducted a prospective, randomized, crossover study. Consecutive eligible patients with ARDS received sessions of conventional mechanical ventilation (CMV) with recruitment maneuvers (RMs), followed by HFO-TGI with RMs, or vice versa. Each ventilatory technique was administered for 8 hours. The order of administration was randomly assigned. Arterial/central venous blood gas analysis and measurement of hemodynamic parameters and EVLW were performed at baseline and after each 8-hour period using the single-indicator thermodilution technique. Results: Twelve patients received 32 sessions. PaO2/FiO2 and respiratory system compliance were higher (p<0.001 for both), while EVLW indexed to predicted body weight (EVLWI) and oxygenation index were lower (p=0.021 and 0.029, respectively) in HFO-TGI compared with CMV. There was a significant correlation between PaO2/FiO2 improvement and EVLWI drop during HFO-TGI (Rs=-0.452, p= 0.009). Conclusions: HFO-TGI improves gas exchange and lung mechanics in ARDS, and potentially attenuates EVLW accumulation

Effectiveness of Early Mobilization in Hospitalized Patients with Deep Venous Thrombosis

Deep venous thrombosis (DVT) is a common problem among hospitalized patients. It places the patient at risk for pulmonary embolism (PE), recurrent thrombosis, and post-thrombotic syndrome (PTS). In particular, up to 50% of patients with proximal DVT of the lower extremity develop PE. Because of the high mortality rate, there is a great concern from physiotherapists and physicians regarding patient’s treatment in the hospital setting. Thus, the purpose of the present review is to examine the effectiveness of early mobilization on acute leg DVT of lower extremity in hospitalized patients. Current evidence showed that early mobilization, i.e., walking and/or exercising, with anticoagulation and leg compression may be encouraged in patients with acute DVT. Recent studies reported the benefits of reduction in pain and edema, with improvement in quality of life when using the therapeutic strategy of early mobilization in patients with DVT. Early mobilization does not appear to increase the risk of developing PE, progression of an existing DVT, or developing a new DVT. Further research with larger hospitalized patient samples is required to determine the appropriate time in which ambulation should initiate after DVT, and whether exercise (regular or vigorous) or not exercise is more effective for DVT, PE, and PTS

Advances in the Clinical Management of Cardiac Arrest

Cardiac arrest constitutes an extremely life-threatening condition that inevitably and promptly results in death if left untreated. Cardiac arrest outcomes still remain very poor, especially when the presenting cardiac rhythm is nonshockable. Important, recent, clinical research has focused on the quality of cardiopulmonary resuscitation (CPR), the mechanical augmentation of the circulation during CPR, CPR drugs, and therapeutic hypothermia. Chest compression depth of at least 51 mm increases the probability of neurologically favorable survival. Despite initially promising results, a large effectiveness study failed to confirm the efficacy of the mechanical augmentation of the circulation. Epinephrine has finally been shown to slightly improve functional outcome after out-of-hospital cardiac arrest, especially when given early. In a recent, in-hospital study of 268 patients, the addition of vasopressin and methylprednisolone during CPR and the administration of hydrocortisone in postresuscitation shock improved functional outcome after vasopressor-requiring cardiac arrest; however, corticosteroid efficacy still needs to be separately confirmed in a large, international trial. Lastly, preliminary human data may support the conduct of high quality trials evaluating the efficacy of beta adrenergic antagonists in shockable cardiac arrest. The purpose of this paper is to review these potentially important advances in the management of cardiac arrest.

Current Pharmacological Advances in the Treatment of Cardiac Arrest

Cardiac arrest requires immediate treatment, in order to prevent patient death. Cardiac arrest outcomes still remain very poor, especially when the patient requires vasopressor treatment. Vasopressors have been advocated, in order to increase the coronary and cerebral perfusion pressure during cardiopulmonary resuscitation (CPR). Recent data suggest an epinephrine-related benefit with respect to short- and long-term outcomes, only when epinephrine is administered within the first 10 min of collapse. Also, increasing the epinephrine dosing interval from 3-5 to 6-10 min during CPR may be associated with improved long-term outcomes. In the in-hospital setting, the combination of vasopressin, epinephrine, and corticosteroid supplementation during and after CPR (in the presence of postresuscitation shock) may be superior to epinephrine alone during CPR. The use of new formulations of amiodarone, potentially devoid of serious hypotensive effects, may contribute to increased rates of sustained return of spontaneous circulation in patients with ventricular fibrillation / pulseless ventricular tachycardia cardiac arrest. Encouraging preliminary results have been reported on the use of beta blockers in patients with shockable cardiac arrest. Other potentially promising pharmacological interventions include the use of cariporide, nitrates (and particularly inhaled nitric oxide), noble gases, levosimendan, and erythropoietin. The purpose of the current paper is to review the clinical and laboratory evidence that support new and potentially useful pharmacological interventions during CPR

Nasal High Flow Oxygen in Respiratory Failure

High flow nasal cannula system or nasal high flow oxygen is an oxygen delivery device which administers heated, humidified high flow oxygen with concentrations from 21% to 100% and with a flow rate up to 60 L/min in adults. It generates many physiologic effects to respiratory system with a lot of clinical applications. Indeed, greater comfort and tolerance, more effective oxygenation, and improved breathing pattern with increased tidal volume and decreased respiratory rate and dyspnea has constantly been detected. Therefore, it can be used to improve cardiogenic pulmonary edema and hypoxemic respiratory failure of any cause, postoperatively, during post-extubation, as well as for palliative car

Pulmonary Hypertension Due to Chronic Thromboembolic Disease Complicated with Hemoptysis and Infection

A 45 year old woman developed exertional dyspnea after surgical removal of uterine fibroids. Heart ultrasound suggested the presence of right heart enlargement and stress due to pulmonary arterial hypertension, whereas the subsequent CT angiography revealed pulmonary embolism. Anticoagulants were initiated. Perfusion defects were noticeable in lung perfusion scan 6 months after the initiation of anticoagulant therapy, while CT angiography was negative for pulmonary embolism. The diagnosis of chronic thromboembolic pulmonary hypertension was initially set and subsequently confirmed by right heart catheterization. Deterioration of dyspnea and right heart dysfunction led to administration of intravenous epoprostenol through a tunneled central venous catheter. After 6 months the patient was admitted to the intensive care unit with fever, hemoptysis, lung infiltrates, and acute-on-chronic hypoxemic respiratory failure. Bronchial artery embolization, oxygen therapy, and antibiotics led to clinical improvement

Near-infrared spectroscopy using indocyanine green dye for minimally invasive measurement of respiratory and leg muscle blood flow in patients with COPD

Reliability of Near-infrared spectroscopy (NIRS), measuring indocyanine green (ICG) for minimally invasive assessment of relative muscle blood flow during exercise has been examined in fit young individuals, but not in COPD. Here we ask whether it could be used to evaluate respiratory and locomotor muscle perfusion in COPD patients. Vastus lateralis muscle blood flow (MBF, the reference method calculated from arterial and muscle ICG concentration curves) and a blood flow index (BFI, calculated using only the (same) muscle ICG concentration curves) were compared in 10 patients (FEV1:51{plus minus}6%predicted) at rest and during cycling at 25%, 50%, 75% and 100% of WRpeak. Intercostal muscle MBF and BFI were also compared during isocapnic hyperpnea at rest, reproducing ventilation levels up to those at WRpeak. Intercostal and vastus lateralis BFI increased with increasing ventilation during hyperpnea (from 2.5{plus minus}0.3 to 4.5{plus minus}0.7nM/s) and cycling load (from 1.0{plus minus}0.2 to 12.8{plus minus}1.9nM/s), respectively. There were strong correlations between BFI and MBF for both intercostal (r=0.993 group mean data, r=0.872 individual data) and vastus lateralis (r=0.994 group mean data, r=0.895 individual data). Fold changes from rest in BFI and MBF did not differ for either the intercostal muscles or the vastus lateralis. Group mean BFI data showed strong interrelationships with respiratory and cycling workload, and whole body metabolic demand (r ranged from 0.913 to 0.989) simultaneously recorded during exercise. We conclude that BFI is a reliable and minimally invasive tool for evaluating relative changes in respiratory and locomotor muscle perfusion from rest to peak exercise in COPD patient groups