Articles: mechanical-ventilation.
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Pneumothoraces are classified as spontaneous, traumatic, and iatrogenic. Spontaneous pneumothoraces (SP) occur without recognized lung disease (primary, PSP) or due to an underlying lung disease (secondary, SSP). Treatment of PSP and SSP has been quite heterogeneous in the United States; adoption of the recently published American College of Chest Physicians guidelines will hopefully improve care. ⋯ Iatrogenic pneumothoraces appear most commonly due to transthoracic needle aspiration and may be treated in carefully selected patients with observation. The presence of underlying emphysema in the setting of an iatrogenic pneumothorax usually mandates placement of a drainage catheter. Newer mechanical ventilation modes and strategies may limit the development of positive pressure ventilation- related iatrogenic pneumothoraces.
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The purpose of this study was to determine the effectiveness of airway pressure release ventilation in children. DESIGN: Prospective, randomized, crossover clinical trial. SETTING: This study was conducted in our 33-bed pediatric intensive care unit at The Children's Hospital of Philadelphia. PATIENTS: Patients requiring mechanical ventilatory support and weighing >8 kg were considered for enrollment. Patients were excluded if they required mechanical ventilatory support for >7 days or required >.50 Fio(2) for >7 days before enrollment. Patients with documented obstructive airway disease and congenital or acquired heart disease were excluded as well. INTERVENTIONS: Each patient received both volume-controlled synchronized intermittent mechanical ventilation (SIMV) and airway pressure release ventilation (APRV) via the Drager Evita ventilator (Drager, Lubeck, Germany). Measurements were obtained after the patient was stabilized on each ventilation mode. Stabilization was defined as oxygenation, ventilation, hemodynamic variables, and patient comfort within the acceptable range for each patient as determined by the bedside physician. After measurements were obtained on the initial mode of ventilation, the subjects crossed over to the alternative study mode. Stabilization was again achieved, and measurements were repeated. After completion of the second study measurements, patients were placed on the ventilation modality preferred by the bedside clinician and were followed through weaning and extubation. Measurements: Vital signs, airway pressures, minute ventilation, Spo(2), and E(T)CO(2) were recorded at enrollment and at each study condition. MAIN ⋯ Using APRV in children with mild to moderate lung disease resulted in comparable levels of ventilation and oxygenation at significantly lower inspiratory peak and plateau pressures. Based on these findings, we plan to evaluate APRV in children with significant lung disease.
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To review the clinical use of noninvasive positive pressure ventilation (NPPV) in both acute hypoxic and hypercarbic forms of pediatric respiratory failure, including its mechanism of action and implementation. DATA SOURCES: Studies were identified through a MEDLINE search using respiratory failure, pediatrics, noninvasive ventilation, and mechanical ventilation as key words. STUDY SELECTION: All original studies, including case reports, relating to the use of noninvasive positive pressure in pediatric respiratory failure were included. Because of the paucity of published literature on pediatric NPPV, no study was excluded. DATA EXTRACTION: Study design, numbers and diagnoses of patients, types of noninvasive ventilator, ventilator modes, outcome measures, and complications were extracted and compiled. DATA SYNTHESIS: For acute hypoxic respiratory failure, all the studies reported improvement in oxygenation indices and avoidance of endotracheal intubation. The average duration of NPPV therapy before noticeable clinical improvement was 3 hrs in most studies, and NPPV was applied continuously for 72 hrs before resolution of acute respiratory distress. In patients with acute hypercarbic respiratory failure, application of NPPV resulted in reduction of work of breathing, reduction in CO(2) tension, and increased serum bicarbonate and pH. These patients are older than patients in the acute hypoxic respiratory failure group and, in addition to improved blood gas indices, they reported improvement in subjective symptoms of dyspnea. Improvement in gas exchange abnormalities and subjective symptoms occurred within the same time span (the first 3 hrs) as in the acute hypoxic respiratory failure group. However, use of noninvasive techniques in patients with acute hypercarbic respiratory failure continued after resolution of acute symptoms. Complications related to protracted use of NPPV were common in this group. ⋯ NPPV has limited benefits in a group of carefully selected pediatric patients with acute hypoxic and hypercarbic forms of respiratory failure. The routine use of this technique in pediatric respiratory failure needs to be studied in randomized controlled trials and better-defined patient subsets.
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Jornal de pediatria · Sep 2000
[High frequency oscillation ventilation compared to conventional mechanical ventilation plus exogenous surfactant replacement in rabbits]
(a) to evaluate the effect on oxygenation and ventilation of rabbits with induced surfactant depletion when they are submitted to a conventional mechanical ventilation, plus a small dose of exogenous surfactant; (b) to compare this group with another group submitted to a High Frequency Oscillation (HFO) without exogenous surfactant administration. ⋯ In ARDS animal model a protect mechanical ventilation strategy as HFO by itself promotes a fast and persistent increase in the oxygenation, with superior levels than those observed in animals treated with conventional mechanical ventilation plus exogenous surfactant replacement.
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Pediatr Crit Care Me · Jul 2000
Comparison of predictors of extubation from mechanical ventilation in children.
Unsuccessful extubation from mechanical ventilation increases mortality and morbidity. Therefore, the identification of an accurate predictor of successful extubation is desirable. This study was designed to determine whether the results of easily performed respiratory measurements, particularly if reported as "combined extubation" indices, were better predictors of extubation failure in a pediatric population than were readily available clinical data. DESIGN: Prospective observational study. SETTING: Tertiary pediatric intensive care unit. PATIENTS: All children who required mechanical ventilation for >/=24 hrs during a 12-month period and whose parents gave informed written consent. INTERVENTIONS: Respiratory function measurements were made (on average) 7 hrs (range, 0.2-25.0 hrs) before extubation. Arterial blood gas results were obtained immediately before extubation. The values of each predictor associated with maximum sensitivity and specificity were determined, and the areas under receiver operator characteristic curves were compared to determine the most accurate predictor of successful extubation. MEASUREMENTS AND MAIN ⋯ Volume measurements during pediatric mechanical ventilation may facilitate successful extubation.