Chest
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Bedside percutaneous dilational tracheostomy was performed by critical care attending physicians or supervised pulmonary and critical care fellows on 100 patients in the ICU at Cook County Hospital, Chicago, over a 3-year period. A needle is inserted in the first or second tracheal interspace followed by a guidewire. The tract is enlarged with a series of dilators to allow placement of a standard tracheostomy tube. ⋯ Comparison of percutaneous dilational tracheostomy with two other techniques of percutaneous tracheostomy reveals a similar success rate with a lower incidence of serious complications. Bedside percutaneous dilational tracheostomy can be performed in the ICU by trained physicians with a low complication rate. We believe it to be the procedure of choice for many critically ill patients who require tracheostomies.
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of BiPAP nasal ventilation and ventilation via iron lung in severe stable COPD.
The effects of noninvasive ventilators on COPD remain controversial because of their obscure mechanisms. A randomized crossover study, using iron lung and positive pressure nasal ventilation (BiPAP) each for 40 min, was performed in 11 stable patients with severe COPD. Throughout the study, we monitored surface EMGdi, EMGst, ECG, SaO2, ETCO2, and the movements of RC and AB. ⋯ No statistically significant improvement was found in view of the above parameters. However, the percentage of iEMGst change after 40-min BiPAP ventilation, compared with the baseline, was much more significant in patients with FEV1 below 0.55 L than those with FEV1 above 0.55 L (n = 4:7, delta iEMGst -62.93 percent +/- 23.27 percent vs 32.45 percent +/- 42.79 percent, p = 0.0056). delta iEMGst correlated significantly with FEV1 during BiPAP ventilation (p < 0.05, r = 0.59). We conclude that the iEMGst during short-term BiPAP ventilation correlates with the severity of the disease.
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To examine the impact of pulse oximetry on the use of arterial blood gas and other laboratory determinations and to examine predictors of the use of arterial blood gas measurements. ⋯ The implementation of pulse oximetry in this manner gives an idea how effective the technology will be in reducing the use of arterial blood gas determinations without guidelines for the use of pulse oximetry. As only a marginal decrease was observed in the total population of medical and surgical patients, and only on the night shift, formal and standardized guidelines for the most efficient use of pulse oximetry should be considered. If these were considered, pulse oximetry may indeed make a significant contribution to improving the efficiency of care services.
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Despite encouraging results seen following bone marrow transplantation (BMT), it has been observed that once these patients become critically ill and require medical intensive care unit (MICU) admission, the chances of survival are poor. We hypothesized that while mechanical ventilation would be an important predictor for death in the MICU, those patients not requiring mechanical ventilation could be successfully discharged from the MICU. The records of 36 patients with 43 admissions to the MICU following BMT were analyzed. ⋯ The average length of stay for the survivors was 4.4 + 3.0 days, which was significantly less than the 17.8 +/- 24.0 days for those patients not surviving (p < 0.001). These data indicate that admission to the MICU may result in a beneficial outcome for critically ill patients with BMTs, but for those requiring mechanical ventilation due to respiratory failure, the chances of survival are poor. This information may be useful for providing patients with BMTs and their families with realistic estimates of prognosis prior to transfer to the MICU and mechanical ventilation.
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To determine whether continuous Fick cardiac output measurement is applicable to exercise testing, cardiac output data obtained by the continuous Fick method (Qcf) during exercise were compared with data obtained by the thermodilution method (Qth). Seventeen patients with old myocardial infarction underwent a 1-min or 3-min incremental exercise test (protocols 1 and 2, respectively). During exercise, the oxygen consumption (VO2), arterial oxygen saturation (SaO2), and mixed venous oxygen saturation (SvO2) were monitored continuously. ⋯ In exercise protocol 2, SvO2 almost reached a steady-state by the end of each stage. The correlation between Qcf and Qth was good in protocol 1 (r = 0.86), except in phases 2 and 4, and was also good in protocol 2 (r = 0.80). We conclude that the continuous Fick method may be applicable for determining the cardiac output during exercise provided that the variation in SvO2 is slight.