Chest
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The aim of this study was to describe the facility, patient population, outcome of treatment, and survival of patients transferred to a regional weaning center (RWC) after prolonged mechanical ventilation in the ICU setting. ⋯ Selected patients who become ventilator dependent for prolonged periods in the ICU may be transferred to an RWC with the expectation of successful weaning in a majority of cases.
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Although nasal continuous positive airway pressure (CPAP) is effective in the treatment of most patients with obstructive sleep apnea (OSA), there is a small group of such patients in whom rapid eye movement (REM) hypoventilation and CO2 retention persist despite the use of CPAP and supplemental oxygen. In this report we describe our experience with nocturnal nasal ventilation (nocturnal nasal positive pressure ventilation [NIPPV] in such patients and its effectiveness in reversing daytime hypercapnia. Thirteen patients, aged 28 to 69 years, with severe OSA confirmed on polysomnography, failed to respond to initial CPAP therapy. ⋯ We believe this improvement is the result of improved central ventilatory drive. Short-term NIPPV provides lasting benefits allowing the majority of such patients to resume CPAP therapy. Short-term intervention with this therapy should be considered as an interim measure in patients with severe hypercapnic OSA who fail to respond to initial CPAP therapy.
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Case Reports
Endotracheal tube and tracheobronchial obstruction as causes of hypoventilation with high inspiratory pressures.
Two cases of difficult ventilation are presented, the first caused by endotracheal tube obstruction with nasal turbinate, and the second caused by tracheobronchial obstruction with blood clots. The clinical presentation in each case was characterized by extreme difficulty in ventilating and severe hypercapnia despite vigorous ventilatory efforts with either a mechanical ventilator or resuscitator bag. A simple manipulation of the endotracheal tube cuff helped to differentiate between increased impedance caused by endotracheal tube obstruction as opposed to increased respiratory system impedance beyond the tip of tube. In the second patient, in whom even a short interruption of ventilation was poorly tolerated, simultaneous rigid bronchoscopy (for removal of intratracheal masses) and ventilation via endotracheal tube were successfully performed.
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This was a prospective study of 52 patients that were extubated in our medical intensive care unit. Rapid shallow breathing, represented by a ratio of frequency to tidal volume (f/VT) of more than 105, was evaluated either on continuous positive airway pressure or pressure support prior to extubation as a marker of extubation outcome. Twelve out of 13 patients (92 percent) with rapid shallow breathing (f/VT ratio > 105) were successfully extubated. ⋯ A measured f/VT ratio of less than 105 had a sensitivity and specificity of 72 and 11 percent, respectively, for extubation success. Patients who had unsuccessful outcomes were ventilated for a significantly more prolonged period (9.6 +/- 6.8 d vs 4.6 +/- 3.9 d, unpaired t test, p = 0.004). We conclude that the presence of rapid shallow breathing during a weaning trial with the patient on partial ventilatory support does not necessarily preclude successful extubation.