News - Part 3

Decreasing Prevalence of Pleural Calcifications Among Metsovites With Nonoccupational Asbestos Exposure

Decreasing Prevalence of Pleural Calcifications Among Metsovites With Nonoccupational Asbestos ExposureAn epidemiologic investigation performed in the Metsovo area of northwestern Greece (population around 5,000) 20 years ago revealed that more than half of the adult population presented with pleural calcifications (PCs). Soon after (from 1981 to 1985), in the same area a mesothelioma “epidemic” was observed (ie, an incidence 300-fold higher than expected). Both phenomena were attributed to “luto,” a whitewash containing tremolite, that was used by practically all Metsovites from 1940 to 1950 and was gradually abandoned. In 1950, it was still used by 88% of the population, in 1960 by 68%, in 1970 its use had dropped to 37%, and in 1980 to 15%. Now its use has been completely substituted for by modern materials. The incidence of mesothelioma in the area of Metsovo, following the fading use of luto, has dropped between 1985 to 1994 to one third of the original incidence. Read more »

High-Frequency Oscillatory Ventilation in Adults: Predictors of Mortality

Multivariate analysis identified OI at 24 h after HFOV initiation as the most significant posttreatment predictor of mortality. Derdak and colleagues also identified OI trend as the most significant posttreatment predictor of survival regardless of assigned ventilator, with the 16-h OI as the most discriminating time point. Fort and colleagues identified the fact that an OI of > 47 predicted mortality with a sensitivity and specificity of 100%. In a large retrospective assessment of HFOV therapy in 10 pediatric ICUs, OI at 24 h also was found to be an important predictor of survival. We found that a 24-h OI of 24 h was a reasonable predictor of survival, but that it was not as significant as the continuous OI value. In the ARDS population, with such an array of confounding risk factors, multivariate models may be more helpful than a single variable in predicting mortality. Nevertheless, OI may serve as an additional indicator of the probability of survival. Read more »

High-Frequency Oscillatory Ventilation in Adults: HFOV Combined With Other Therapies

High-Frequency Oscillatory Ventilation in Adults: HFOV Combined With Other TherapiesThe observed pneumothorax rate (21.8%) is higher than the rates observed in studies evaluating conventional treatment strategies in adults with ARDS, in which barotrauma rates ranged from 7 to 14%. Derdak and colleagues reported pneumothorax rates of 9% and 12%, respectively, in the HFOV and CV groups. The higher rate in the current study was likely due to the patients’ severity of illness. Another possible explanation relates to differences in HFOV utilization and settings. However, this explanation is not likely, since the applied mPaw was not higher in the current study than those used in previous studies evaluating HFOV, and there was no difference in the pneumothorax rate among the three ICUs. Read more »

High-Frequency Oscillatory Ventilation in Adults: Hemodynamics

The 30-day mortality rate in the current study was 61.7%, which is higher than those in the studies by Fort et al and Derdak et al, despite similar APACHE II scores. The higher mortality rate in the current study may relate to patient parameters that are not captured in the APACHE II score, such as burn injury or organ/bone marrow transplantation.
The higher mPaw applied during HFOV therapy was associated with an early and nonpersistent increase in PAOP, a small persistent increase in CVP, and a small decrease in CO. The increase in PAOP and CVP likely is related to changes in cardiac transmural pressure during HFOV therapy, however, without direct measurements of intrathoracic pressure, we cannot confirm this. These findings are very similar to those of three previous studies, which also reported an early rise in CVP and/or PAOP, while Mehta and colleagues observed a significant reduction in CO with the application of HFOV. Two pediatric studies also found significant reductions in CO measured noninvasively in infants converted from CV to HFOV. Read more »

High-Frequency Oscillatory Ventilation in Adults: Discussion

High-Frequency Oscillatory Ventilation in Adults: DiscussionThe purpose of the current study was to summarize the experience with HFOV therapy in three Toronto medical/surgical ICUs. We observed the following. First, HFOV is used as rescue therapy in adults with ARDS due to a wide variety of etiologies, when patients are already requiring high Fio2 and/or high airway pressures. Second, the use of HFOV is associated with improvements in ventilation and oxygenation, the latter permitting significant reductions in delivered Fio2. Third, 26% of patients had HFOV therapy discontinued due to difficulties with oxygenation, ventilation, or hemodynamics. Fourth, the incidence of pneumothorax is higher in this population than in other reported ARDS patients. Fifth, compared with survivors, nonsurvivors are older, have higher severity of illness, require higher peak pressures during CV, and have received CV for a greater number of days prior to receiving HFOV therapy. Read more »

High-Frequency Oscillatory Ventilation in Adults: Patient Outcomes With HFOV

Patient outcomes and the use of concomitant therapies for ARDS such as inhaled nitric oxide (NO) are presented in Table 2. The median duration of HFOV therapy in all patients was 3.5 days (25 to 75% CI, 0.8 to 6.8 days). Neuromuscular blocking agents were administered continuously during HFOV therapy to 90% of patients. Twenty-one percent of patients exhibited spontaneous respirations at some time during HFOV therapy. At 30 days, the mortality rate was 61.7%. Of the survivors, approximately half still required ventilatory support. The mortality rate remained constant throughout the 4 years. Read more »

High-Frequency Oscillatory Ventilation in Adults: HFOV Weaning and Transition to CV

High-Frequency Oscillatory Ventilation in Adults: HFOV Weaning and Transition to CVThirty-two patients (20.5%) had a pulmonary artery catheter during HFOV. At baseline, patients with a pulmonary artery catheter did not differ from those without a PA catheter with regard to age, acute physiology and chronic health evaluation (APACHE) II score, LIS, Fio2, Pao2/Fio2 ratio, OI, Paco2, ventilator pressures, or ventilator days prior to HFOV. Central venous pressure (CVP) increased immediately after starting therapy with HFOV and remained higher than the value during CV throughout the 72 h (p = 0.01) [Fig 2, bottom, B]. Pulmonary artery occlusion pressure (PAOP) was significantly greater than the baseline value at 3 h after initiation of HFOV (p = 0.03) and 6 h after initiation of HFOV (p = 0.03), but the difference did not persist beyond 6 h. Cardiac output (CO) decreased significantly immediately after starting therapy with HFOV and remained lower than the baseline value throughout the study (p = 0.0043), but it was within the normal range. Read more »

High-Frequency Oscillatory Ventilation in Adults: Results

From January 1998 to February 2002, 156 patients with ARDS and severe hypoxemia underwent 171 trials of HFOV (Table 1). The mean (± SD) duration of ARDS prior to HFOV was 3.5 ± 4.3 days (median duration, 2 days; 25 to 75% confidence interval [CI], 0.2 to 5 days). The etiology of ARDS included sepsis (88 patients), pneumonia (26 patients), and aspiration of gastric contents (8 patients). All patients had severe ARDS, as evidenced by a mean lung injury score (LIS) of 3.5 ± 0.4, a mean Pa02/Fl02 ratio of 91 ± 48 mm Hg, and an OI of 31.2 ± 13.7. Airway pressures during CV immediately prior to HFOV are presented in Table 1. Read more »

High-Frequency Oscillatory Ventilation in Adults: HFOV

High-Frequency Oscillatory Ventilation in Adults: HFOVHFOV was introduced into each center between 1998 and 1999. Data were extracted from the records of all patients who were treated at each center, from the time of introduction until January 2002. The data were reviewed by individuals not involved with data extraction, were entered into a database, and were screened for aberrant entries. Statistical analysis was performed in two prospectively defined steps. First, summary data were tabulated with means, SDs, and percentages, as appropriate, and the trends of ventilator settings and physiologic variables were evaluated with repeated-measures analysis of variance. A t test was used to evaluate the changes from baseline compared with specific time points. In the second step, differences in baseline risk and HFOV response associated with survival were explored. Logistic regression was used to identify significant baseline characteristics associated with mortality. Read more »

High-Frequency Oscillatory Ventilation in Adults: Materials and Methods

In adults with ARDS, the experience with HFOV is limited to five observational studies and one randomized controlled trial. The observational studies reported significant improvements in oxygenation using an aggressive open lung strategy during HFOV, and the two larger studies suggested better outcomes when HFOV is applied early in the course of ARDS. Derdak and colleagues conducted a multicenter randomized, controlled trial comparing HFOV with conventional pressure control ventilation strategy in 148 adults with early-phase ARDS. Applying a significantly higher mPaw in the HFOV group, there was an early improvement in the Pa02/fraction of inspired oxygen (Fio2) ratio compared with the conventional group. However, this difference did not persist beyond 24 h. the mortality rate in the HFO group was 37%, compared with 52% in the CV group, but this difference was not statistically significant. They concluded that HFOV is a safe and effective mode of ventilation for the treatment of ARDS in adults. Read more »

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