Category Archives: Respiratory

ICM year in review: respiratory, cardiodynamics and renal

This first session of the day in room Lisbon was a rapid run through of the journals’ most important papers of the last year  – a bumper year as the journals impact factor has soared.

Some notes below:

Respiratory papers

IC-GLOSSARI, the Intensive Care Global Study on Severe Acute Respiratory Infection which was a great ESICM project led by Yasser Sakr and is described as “a multicenter, multinational, 14-day inception cohort study”, in which I admit a COI in that i was involved on one of the sites, but a good paper in that it crossed continents and showed that admission to the ICU for severe lung infection is not only common but also associated with high morbidity and mortality rates.

http://link.springer.com/article/10.1007%2Fs00134-015-4206-2

ECMO epidemiology, this German study showed an increase in ECMO use especially amongst more elderly patients, since 2007.  VV ECMO seems to have reached a “plateau” in use. Mortality has decreased over time – the authors attribute this to experience – but is still stunningly high –  58 and 66 % for vv-ECMO and va-ECMO respectively.

http://link.springer.com/article/10.1007%2Fs00134-016-4273-z

ARDS rehabilitation – Pfoh and colleagues examined “physical declines occurring after hospital discharge” in people who survive ARDS and followed up patients for 5 years.  The headline is that most people decline, and older people and those with co-morbidities decline more.

http://link.springer.com/article/10.1007%2Fs00134-016-4530-1

Lung US training – This paper followed 11 respiratory therapists who had never used ultrasound before over 9 months and claims that 12 scans is the magic number to attain competence.  The jury is out…

http://link.springer.com/article/10.1007%2Fs00134-015-4102-9

The TRACHUS trial looked at ultrasound for tracheostomy – a good idea surely.  Anyway the paper says that it is safe and useful.  As @PhilMcglone said in his review for The Bottom Line – Why choose between bronchoscopy and ultrasound when we can use both?

http://link.springer.com/article/10.1007%2Fs00134-016-4218-6

Finally in the respiratory section this directions-type paper from Jeremy Beitler and the ARDSnet group (now ARDSne(x)t – see what they did there…) on personalising ARDS treatment. The research agenda is going to ask simultaneously both “whether a treatment affords clinically meaningful benefit and for whom.” Watch this space. Or read the paper:

http://link.springer.com/article/10.1007%2Fs00134-016-4331-6

Cardiodynamics and Ultrasound

Antoine Vieillard-Baron discussed the most important papers from this excitingly titled topic.

The FENICE trial was another landmark “global inception cohort study” and looked at fluid management and fluid boluses ( et al).  It showed massive variation in what a fluid bolus is and how it is used.  The question posed by AVL was why did only 2% of physicians use echo to manage fluid? Not enough trainers? Too difficult? Maurizio himself weighed in on the twitter chat below:

Then a study from 3 countries on point of care ultrasound use was presented.  Adrian has reviewed it nicely here for the NEXT journal club – or read the paper.  POCUS is underused generally, and only half the CVC insertions were performed under US guidance.

http://link.springer.com/article/10.1007%2Fs00134-015-3952-5

Finally a nice review article (authored by the presenter) on how to use ultrasound in ventilation management – 4 key areas:

  1. Assessment of cardiac function
  2. Assessment of diaphragmatic function
  3. Assessment of lung function
  4. Identification of pleural effusion

http://link.springer.com/article/10.1007%2Fs00134-016-4245-3

Kidneys

Matt wrote a nice blog on this yesterday, so briefly some of the papers discussed today were:

Statins in heart valve surgery

http://link.springer.com/article/10.1007%2Fs00134-016-4358-8

The kidney injury epidemiology study (AKI-EPI)

http://link.springer.com/article/10.1007%2Fs00134-015-3934-7

And the Truche study – looking again at continuous vs intermittent RRT:

http://link.springer.com/article/10.1007%2Fs00134-016-4404-6

Critical Care Refresher Course: Respiratory and Airways Management

Management of Tracheostomy (Waldmann)

EPIC Study 1992 – 12% of ICU pts had tracheostomy insitu

On the Right Trach – http://www.ncepod.org.uk/2014report1/downloads/OnTheRightTrach_Summary.pdf 

NAP4 – http://www.rcoa.ac.uk/document-store/nap4-executive-summary

Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes – http://rc.rcjournal.com/content/59/6/895.full

Meta-analysis comparison of open versus percutaneous tracheostomy. – https://www.ncbi.nlm.nih.gov/pubmed/17334304
TRACMAN trial – https://www.ncbi.nlm.nih.gov/pubmed/23695482 

Tracheostomy Global collaborative – http://globaltrach.org/

Protective Lung Ventilation (Gattinoni)

Aim of resp support is to buy time whilst minimising damage

Modeling the time-course of ventilator-induced lung injury: what can we learn from interspecies discrepancies? http://link.springer.com/article/10.1007/s00134-011-2394-y

Lung anatomy, energy load, and ventilator-induced lung injury https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679691/

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome — http://www.nejm.org/doi/full/10.1056/NEJMsa1410639#t=article

 

Management of bariatric patients (Rubulotta)

WHO interactive map on epidemiology of obesity – http://www.ncdrisc.org/map-obesity-prevalence.html 

Neck circumference – height ratio in predicting sleep-related breathing disorder https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773632/ 

STOP-BANG for OSA screening – http://www.stopbang.ca/osa/screening.php

Ventilation strategies in obese pts undergoing surgery: quantitative systematic review & meta-analysis http://bja.oxfordjournals.org/content/109/4/493.full

Protective Ventilation With Higher Versus Lower PEEP During General Anesthesia for Surgery in Obese Patients (PROBESE) protocols – https://clinicaltrials.gov/ct2/show/NCT02148692 

High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60416-5/abstract?rss=yes 

I-NVNICTUS

Mortality of immunocompromised patients who need mechanical ventilation has reduced dramatically but remain relatively high (40-60%)

NIV does reduce intubation rates in these patients in older trials (but at that time, mortality for intubation was 80% rather than the lower values found in modern practice)

Multicentre, RCT comparing NIV to O2 on all-cause D28 mortality in immunocompromised patients with hypoxaemic respiratory failure

Inclusion:

  • Adult
    • Haematological/solid tumour OR
    • Solid organ transplant OR
    • Long-tern steroids OR
    • Immunosuppression
  • + Respiratory failure

Excluded other organ failures or likely to need ETT / lots of O2

191 received early NIV, 183 O2. No loss to follow-up.

No difference in mortality at 28 days

MOrtalty

Didn’t matter what diagnosis was (i.e. solid organ or haematological malignancy). However, was powered for mortality of 35% in oxygen group and was much less than this.

7% of patients only received one session of NIV – either due to need for intubation or poor tolerance (who were in the main subsequently intubated)

No difference in intubation rates, length of ICU stay, 6/12 mortality

1/3 of patients across the two groups received HFNO2 but mortality wasn’t any different

Conclusion: Early NIV did not reduce mortality compared with O2 but study underpowered as mortality much less than was predicted.

Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure

NEXT Day: Alone on the Night Shift

One of the things many of us found most challenging when first starting on intensive care was the array of images we might be bombarded with when we first start out – unfamiliar modalities such as MRI, CT with or without angiography are relatively commonplace within our field. Kobus Preller, Consultant Intensivist from Cambridge gave us a fantastic radiology quiz with some spectacular images.

Next up Dr. Garyphalia Poulakou from Greece gave us an excellent talk about choosing the right antibiotics, particularly where KPC carbapenemase producing bacteria are the cause. Even where ‘resistance’ may be a problem, it is important to look at how susceptible a drug may be. Combination therapies offer survival benefit and should be considered in this class of patients. ESBL bacteria hydrolyse third generation cephalosporins and aztreonam. Carbapenems and cephamycines remain stable. They are usually inhibited by beta-lactamase inhibitors but reporting these was previously difficult prior to change in susceptibility breakpoints. The use of beta-lactams with inhibitors in ESBL is a matter of ongoing debate with no proven efficacy outside of urine infection. MRSA strains are resistant to ALL beta-lactams. Vancomycin creep is an important phenomenon when looking at treatment – this is the observation that MICs tend to increase with time, therefore higher MICs predict treatment failure.

Dr. Jordi Mancebo spoke about how to deal with some of the more common yet difficult problems which can happen with the ventilator; how best to predict failure of NIV? Those who take larger tidal breaths on NIV are more likely to progress to endotracheal intubation. He discussed the potential drawbacks of recruitment manoeuvres (including necessary over distension of some lung areas) and the importance of assessing the right ventricular and pulmonary vascular contribution to oxygenation. An echocardiogram is an important investigation in these patients.

EUCAST Breakpoints for Antibiotic Susceptibility

Predictors of mortality in bloodstream infections caused by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae: importance of combination therapy

Prone Positioning in Severe Acute Respiratory Distress Syndrome