American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Apr 1998
ReviewThe American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome.
The acute respiratory distress syndrome (ARDS) continues as a contributor to the morbidity and mortality of patients in intensive care units throughout the world, imparting tremendous human and financial costs. During the last 10 years there has been a decline in ARDS mortality without a clear explanation. The American-European Consensus Committee on ARDS was formed to re-evaluate the standards for the ICU care of patients with acute lung injury (ALI), with regard to ventilatory strategies, the more promising pharmacologic agents, and the definition and quantification of pathologic features of ALI that require resolution. It was felt that the definition of strategies for the clinical design and coordination of studies between centers and continents was becoming increasingly important to facilitate the study of various new therapies for ARDS.
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Am. J. Respir. Crit. Care Med. · Apr 1998
Multicenter StudyUnplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Réanimateurs du Centre-Ouest.
The predisposing factors and complications of unplanned extubation (UEX) in mechanically ventilated adult patients are not well recognized. We designed a prospective multicenter observational study to identify risk factors and describe the complications of UEX. We followed 426 ventilated patients over a 2-mo period. ⋯ One death occurred as a direct consequence of UEX. By use of multivariate analysis, we identified four factors contributing to UEX: chronic respiratory failure, endotracheal tube fixation with only thin adhesive tape, orotracheal intubation, and the lack of intravenous sedation. Considering these factors, we hypothesized that simple measures should be adopted to minimize the incidence of UEX and its related complications: more vigilance during procedures at patients' bedsides, adequate sedation of agitated patients, strong fixation of the tracheal tube, particular attention paid to orally intubated patients, and daily reassessment of the possibility of weaning from the ventilator.
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Am. J. Respir. Crit. Care Med. · Apr 1998
Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome.
The independent effects of chronic disease, age, severity of illness, lung injury score (LIS) and etiology, and preceding nonpulmonary organ-system dysfunction (OSD) on the outcome of acute lung injury (ALI) have not been examined in an exclusively medical-intensive-care-unit (MICU) population. Therefore, 107 consecutive MICU patients with ALI (76% with acute respiratory distress syndrome [ARDS]) were prospectively investigated. The impact of comorbidities, age > 65 yr, acute physiology score (APS), LIS, etiology of ALI, and OSD on hospital survival were studied. ⋯ Multivariate analysis of the ARDS cohort showed similar results, although cirrhosis and malignancy did not reach statistical significance. We conclude that comorbid conditions, older age, and sepsis etiology are independent predictors of hospital death in exclusively MICU patients with ALI (76% of whom satisfied criteria for ARDS). These factors should be considered in analyzing studies of new therapies and interpreting trends in mortality for ALI and ARDS.
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Am. J. Respir. Crit. Care Med. · Apr 1998
Nosocomial pneumonia in patients with acute respiratory distress syndrome.
To describe the epidemiologic and microbial aspects of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS), we prospectively evaluated 243 consecutive patients who required mechanical ventilation (MV) for > or = 48 h, 56 of whom developed ARDS as defined by a Murray lung injury score > 2.5. We did this with bronchoscopic techniques when VAP was clinically suspected, before any modification of existing antimicrobial therapy. For all patients, the diagnosis of pneumonia was established on the basis of culture results of protected-specimen brush (PSB) (> or = 10(3) cfu/ml) and bronchoalvelolar lavage fluid (BALF) (> or = 10(4) cfu/ml) specimens, and direct examination of cells recovered by bronchoalveolar lavage (BAL) (< or = 5% of infected cells). ⋯ The organisms most frequently isolated from patients with ARDS and VAP were methicillin-resistant Staphylococcus aureus (23%), nonfermenting gram-negative bacilli (21%), and Enterobacteriaceae (21%). These findings confirm that microbiologically provable VAP occurs far more often in patients with ARDS than in other ventilated patients. Because these patients are often treated with antibiotics early in the course of the syndrome, the onset of VAP is frequently delayed after the first week of MV, and is then caused mainly by methicillin-resistant S. aureus and other multiresistant microorganisms.