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Competing Interests: Conflicts of interest were reviewed and adjudicated by the co-chairs and co-vice chairs of the guidelines. In the event an individual disclosed a conflict or potential conflict by submitted form or verbally during the process of guidelines, those individuals abstained from voting on related questions. The taskforce followed all procedures as documented in the American College of Critical Care Medicine/Society of Critical Care Medicine (SCCM) Standard Operating Procedures Manual. Drs. Singbartl, Nanchal, Killian, Olson, Karvellas, Subramanian, and Truwit disclosed authorship on several related articles with potential intellectual conflicts explored and adjudicated. Dr. Dionne described volunteer service for Canadian Association of Gastroenterology, American College of Gastroenterology, American Gastroenterological Association, and European Society of Intensive Care Medicine. Dr. Hyzy described volunteer service for American Thoracic Society, Quality Improvement and Implementation Committee, and the SCCM Finance Committee as well as service as an expert witness in a previous medical case involving this subject matter. Taylor advised of service as an author on the SCCM/American Society for Parenteral and Enteral Nutrition (ASPEN) nutrition guidelines and service on the ASPEN research committee. Dr. Huang disclosed service on the American College of Emergency Physicians sepsis task force. Dr. Karvellas disclosed service on an acute liver failure study group. Dr. Hyzy and Dr. Olson disclosed being expert witnesses. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU., Design: The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development., Interventions: In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements., Measurements and Main Results: We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence., Conclusions: Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence., Competing Interests: Conflicts of interest were reviewed and adjudicated by the co-chairs and co-vice chairs of the guidelines. In the event an individual disclosed a conflict or potential conflict by submitted form or verbally during the process of guidelines, those individuals abstained from voting on related questions. The taskforce followed all procedures as documented in the American College of Critical Care Medicine/Society of Critical Care Medicine (SCCM) Standard Operating Procedures Manual. Drs. Singbartl, Nanchal, Killian, Olson, Karvellas, Subramanian, and Truwit disclosed authorship on several related articles with potential intellectual conflicts explored and adjudicated. Dr. Dionne described volunteer service for Canadian Association of Gastroenterology, American College of Gastroenterology, American Gastroenterological Association, and European Society of Intensive Care Medicine. Dr. Hyzy described volunteer service for American Thoracic Society, Quality Improvement and Implementation Committee, and the SCCM Finance Committee as well as service as an expert witness in a previous medical case involving this subject matter. Dr. Taylor advised of service as an author on the SCCM/American Society of Parenteral and Enteral Nutrition (ASPEN) nutrition guidelines and service on the ASPEN research committee. Dr. Huang disclosed service on the American College of Emergency Physicians Sepsis Task Force. Dr. Karvellas disclosed service on an Acute Liver Failure Study Group. Dr. Hollenberg disclosed that he is a member of American College of Chest Physicians, American Heart Association, and American College of Cardiology. Dr. Olson disclosed that she is a member of American Association for the Study of Liver Disease. Dr. Steadman disclosed that he is a co-author on “Management of the Critically Ill Patient with Cirrhosis: A Multidisciplinary Perspective.” J Hepatology 2015 pending publication, and that he is currently writing guidelines for Anesthesiology Transplant fellowship for the International Liver Transplant Society. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine.)

How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT., Methods: A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses., Results: 1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology., Conclusion: Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training., (© 2021 Acta Anaesthesiologica Scandinavica Foundation.)

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU., Design: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development., Setting: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology., Interventions: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements., Measurements and Main Results: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence., Conclusions: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

Objective: Poor sign-out or handover of care may lead to preventable patient harm. Critically ill patients in intensive care units (ICU) are complex and prone to rapid clinical deterioration. If clinical deterioration occurs, timeliness of appropriate interventions is essential to prevent or reduce adverse outcomes. Therefore sign-outs need to efficiently transmit key information and provide anticipatory guidance. Interventions to improve resident-to-resident ICU sign-outs have not been well described. We conducted a controlled trial to test the effectiveness of a standardised ICU sign-out process to the usual ICU sign-out., Design: Prospective controlled trial., Setting: A 26-bed medical intensive care unit (MICU) in an urban tertiary academic medical centre., Subjects: Residents rotating through the MICU., Interventions: ICU-specific written sign-out template., Methods: Residents completed postcall surveys assessing satisfaction with verbal and written sign-outs and incidence of non-routine events. Our main outcome of interest was the occurrence of non-routine events., Main Results: Compared with the intervention group, on significantly more nights, night float residents in the control group encountered patients who were sicker than sign-out would have suggested (15.94% vs 43.75%; p<0.0001). On significantly fewer nights, night float residents in the intervention group indicated that either something happened to patients that was unexpected (18.84% vs 36.51%; p=0.023) or they were insufficiently prepared for (4.35% vs 35.94%; p<0.0001). Similarly, on fewer nights, residents in the intervention group indicated that they had to perform interventions that were unplanned or unanticipated (15.9% vs 37.7%; p=0.005)., Conclusion: A structured sign-out process compared with usual sign-out significantly reduced the occurrence of non-routine events in an academic MICU., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Unlabelled: While statins are indicated to reduce blood cholesterol levels, they also have anti-inflammatory and immunomodulatory effects. Several observational cohort studies suggested that statins may improve survival and reduce complications in patients with sepsis. Recent randomized controlled studies in critically ill patients have been conducted and published. In this paper we present a meta-analysis of these randomized trials., Methods: An electronic article search through PubMed was performed. Only randomized controlled trials including critically ill adult patients with severe sepsis were retained. A meta-analysis was performed as detailed in text below. Overall analysis including 1818 patients total from 4 studies showed that there was no difference in 60-day mortality between statins (223/903) and placebo (233/899) [risk ratio, 0.930; 95% CI, 0.722 to 1.198]. Similarly, no difference in 28-day mortality was observed between groups (statins 191/907, placebo 199/911; risk ratio 0.953; 95% CI, 0.715 to 1.271). The results of this meta-analysis confirm that the use of statin therapy should not be recommended in the management of severe sepsis in critically ill patients. Statins should be continued with caution and only if necessary, as one study reported that the statin group had a higher rate of hepatic and renal failure.

Because of the physiological stresses of commercial air travel, the presence of a pneumothorax has long been felt to be an absolute contraindication to flight. Additionally, most medical societies recommend that patients wait at least 2 weeks after radiographic resolution of the pneumothorax before they attempt to travel in a nonurgent fashion via commercial air transport. This review sought to survey the current body of literature on this topic to determine if a medical consensus exists; furthermore, this review considered the scientific support, if any, supporting these recommendations. In this review, we found a paucity of data on the issue and noted only a handful of prospective and retrospective studies; thus, true evidence-based recommendations are difficult to develop at this time. We have made recommendations, when possible, addressing the nonurgent commercial air travel for the patient with a recent pneumothorax. However, more scientific research is necessary in order to reach an evidence-based conclusion on pneumothoraces and flying., (Copyright © 2013 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Rationale: Our previous studies in children with acute lung injury/acute respiratory distress syndrome demonstrated improved outcomes with exogenous surfactant (calfactant) administration. Sample sizes in those studies were small, however, and the subject populations heterogeneous, thus making recommendations tenuous., Objective: To investigate the efficacy of surfactant administration in a larger, more homogenous population of children with lung injury/acute respiratory distress syndrome due to direct lung injury., Design and Setting: Masked, randomized, placebo-controlled trial in 24 children's hospitals in six different countries., Patients and Methods: Children 37 weeks postconception to 18 years old with lung injury/acute respiratory distress syndrome due to direct lung injury were randomized to receive up to three doses of 30 mg/cm height of surfactant (calfactant) versus placebo (air) within 48 hours of intubation and initiation of mechanical ventilation. The primary outcome was mortality at 90 days. Ventilator-free days, changes in oxygenation, and adverse events were also assessed., Results: The study was stopped at the sponsor's request after the second interim analysis for presumed futility. A total of 110 subjects were enrolled, with consent withdrawn from one whose data are unavailable. There were no significant differences between groups except in hospital-free days (10.4 ± 7.8 placebo vs 6.4 ± 7.8 surfactant; p = 0.01). Overall 90-day mortality was 11% (seven surfactant, five placebo). No immediate improvement in oxygenation was associated with surfactant administration., Conclusions: Surfactant did not improve outcomes relative to placebo in this trial of children with direct lung injury/acute respiratory distress syndrome. Differences in concentration of the surfactant, failure to recruit the lung during surfactant administration, or using two rather than four position changes during administration are possible explanations for the difference from previous studies. Exogenous surfactant cannot be recommended at this time for children with direct lung injury/acute respiratory distress syndrome.

Objectives: Adult studies have demonstrated the relationship between fluid overload and poor outcomes in acute lung injury/acute respiratory distress syndrome. The approach of pediatric intensivists to fluid management in acute lung injury/acute respiratory distress syndrome and its effect on outcomes is less clear. In a post hoc analysis of our Calfactant in Acute Respiratory Distress Syndrome trial, we examined the relationship of fluid balance to in-hospital outcomes in subjects with acute lung injury/acute respiratory distress syndrome., Design: Calfactant in Acute Respiratory Distress Syndrome was a masked randomized controlled trial of calfactant surfactant versus placebo in pediatric patients with acute lung injury/acute respiratory distress syndrome due to direct lung injury. Caregivers were encouraged to follow a conservative fluid management guideline based on the adult Fluid and Catheter Treatment Trial. Daily fluid balance was collected for the first 7 days after trial enrollment and correlated with clinical outcomes., Patients and Setting: Children admitted to PICUs with acute lung injury/acute respiratory distress syndrome from 24 children's hospitals in six different countries., Intervention: Post hoc analysis of daily fluid balance in subjects from the Pediatric Calfactant in Acute Respiratory Distress Syndrome trial., Measurements and Main Results: Despite the conservative fluid guideline, fluid management was more consistent with a "liberal" approach. On average, study subjects accumulated 1.96 ± 4.2 L/m over the first 7 days of the trial. Subjects who died accumulated on average 8.7 ± 9.5 L/m versus 1.2 ± 2.4 L/m in survivors. Increasing fluid accumulation was associated with fewer ventilator-free days and worsening oxygenation. Multivariable regression models that included age, gender, Pediatric Risk of Mortality score, initial oxygen saturation index and PaO2/FIO2 ratio, injury category, and treatment arm failed to account for the differences in fluid management., Conclusions: Pediatric intensivists generally follow a "liberal" approach to fluid management in children with acute lung injury/acute respiratory distress syndrome. Illness severity or oxygenation disturbance did not explain differences in fluid accumulation but such accumulation was associated with worsening oxygenation, a longer ventilator course, and increased mortality. A more conservative approach to fluid management may improve outcomes in children with acute lung injury/acute respiratory distress syndrome.

Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.

Rationale and Objectives: The aim of this study was to determine the efficacy of hyperpolarized (3)He (HHe) ventilation and apparent diffusion coefficient (ADC) HHe magnetic resonance imaging (MRI) in detecting changes in lung function and microstructure in emphysematous lung after bronchial valve (BV) placement., Materials and Methods: One patient diagnosed with emphysema had nine BVs placed in upper lobe bronchi. Imaging was performed before and 6 months after BV placement. Coronal HHe ventilation MRI was used to assess volume changes in the ventilated portions of the lung. Coronal ADC HHe MRI, acquired with b value pairs of 0 and 1.6 s/cm(2) during a second 10-second breath-hold, was used to compute ADC values., Results: HHe ventilation MRI revealed decreased ventilation in the treated segments of the upper lobes after BV placement. Increased ventilation in the lower lobes and two untreated segments of the left upper lobes were also observed, with an upward shift of the major fissure of the right lung. Whole-lung mean ADC decreased by 6.3% from baseline, from 0.48 ± 0.196 to 0.45 ± 0.176 cm(2)/s (toward healthier values) following BV placement., Conclusions: HHe ventilation MRI detected an increase in whole-lung volume and an interlobar fissure shift indicative of increased ventilation of lower relative to upper lobes. Reduced ADC values suggest increased ventilation to healthy lower lobes at the expense of more diseased, expanded alveolar spaces in the upper lobes distal to BV placement. These results suggest that this ionizing radiation-free method of examining the lungs may offer functional and structural information useful in BV intervention planning., (Copyright © 2011 AUR. Published by Elsevier Inc. All rights reserved.)

Background: Chronic obstructive pulmonary disease (COPD) affects millions of people and has limited treatment options. Surgical treatments for severe COPD with emphysema are effective for highly selected patients. A minimally invasive method for treating emphysema could decrease morbidity and increase acceptance by patients., Objective: To study the safety and effectiveness of the IBV(R) Valve for the treatment of severe emphysema., Methods: A multicenter study treated 91 patients with severe obstruction, hyperinflation and upper lobe (UL)-predominant emphysema with 609 bronchial valves placed bilaterally into ULs., Results: Valves were placed in desired airways with 99.7% technical success and no migration or erosion. There were no procedure-related deaths and 30-day morbidity and mortality were 5.5 and 1.1%, respectively. Pneumothorax was the most frequent serious device-related complication and primarily occurred when all segments of a lobe, especially the left UL, were occluded. Highly significant health-related quality of life (HRQL) improvement (-8.2 +/- 16.2, mean +/- SD change at 6 months) was observed. HRQL improvement was associated with a decreased volume (mean -294 +/- 427 ml, p = 0.007) in the treated lobes without visible atelectasis. FEV(1), exercise tests, and total lung volume were not changed but there was a proportional shift, a redirection of inspired volume to the untreated lobes. Combined with perfusion scan changes, this suggests that there is improved ventilation and perfusion matching in non-UL lung parenchyma., Conclusion: Bronchial valve treatment of emphysema has multiple mechanisms of action and acceptable safety, and significantly improves quality of life for the majority of patients., (Copyright 2009 S. Karger AG, Basel.)

Background: Previous investigations have identified significant interobserver variability in the measurements of central venous pressure and pulmonary artery occlusion pressure in critically ill patients. Large interobserver variability in the measurement of vascular pressures could potentially lead to inappropriate treatment decisions., Objective: We postulated that adding an airway pressure signal (Paw) to pressure tracings of central venous pressure and pulmonary artery occlusion pressure would improve interobserver agreement by facilitating identification of end-expiration., Design: To test this hypothesis, six independent experts used a standard protocol to interpret strip-chart recordings of central venous pressure and pulmonary artery occlusion pressure with or without Paw. Two observers were said to agree if their measurements were within 2 mm Hg of each other. SETTING/SUBJECTS/INTERVENTIONS: A total of 459 strip-chart recordings (303 without Paw and 156 with Paw) were obtained from 121 patients enrolled in the ARDSnet Fluids and Catheters Treatment Trial (FACTT) in 16 different hospitals., Results: Agreement within 2 mm Hg between two measurements was 79% for central venous pressure strips without Paw vs. 86% with Paw. For pulmonary artery occlusion pressure, agreement increased from 71% without Paw to 83% with Paw. The increase in agreement with the addition of Paw was greater for strips demonstrating >8 mm Hg phasic respiratory variation compared with strips demonstrating less phasic respiratory variation., Conclusion: Paw display is a simple, inexpensive method to facilitate the identification of end-expiration that can significantly improve interobserver agreement.

The respiratory system rarely limits exercise in the normal subject. In patients with chronic pulmonary processes or in the elite athlete, however, the respiratory system may indeed be the limiting factor. Common respiratory disorders include chest pain syndromes, cough, exercise-induced asthma, and vocal cord dysfunction. Chronic lung diseases such as asthma, COPD, and interstitial lung disease impact exercise capacity and endurance. Exercise testing can be useful to distinguish acute and chronic pulmonary causes of dyspnea during exercise, as well as to differentiate between cardiac and pulmonary causes.

Objective: To determine the accuracy of a technique using capnography to prevent inadvertent placement of small-bore feeding tubes and Salem sump tubes into the lungs., Setting: Twelve-bed medical intensive care unit (MICU) in a 557-bed teaching hospital., Patients: A total of 25 ventilated adult MICU patients were studied-5 in phase 1 and 20 in phase 2., Design: Phase 1 tested the ability of the end-tidal CO2 (ETCO2) monitor to detect flow (and thus accurately detect CO2) through small-bore feeding tubes. A small-bore feeding tube, with stylet in place, was placed 5 cm through the top of the tracheostomy tube ventilator adapter in five consecutive patients. The distal end of the feeding tube was attached to the ETCO2 monitor. The ETCO2 level and waveform were assessed and recorded. Because CO2 waveforms were successfully detected, a convenience sample of 20 adult MICU patients who were having feeding tubes placed (13 Salem sump tubes, 7 small-bore feeding tubes) was then studied. The technique consisted of attaching the ETCO2 monitor to the tubes and observing the ETCO2 waveform throughout placement., Results: The study hypothesis was supported. Of the seven small-bore feeding tubes tested, all were successfully placed on initial insertion. Placement was confirmed by absence of an ETCO2 waveform and by radiograph. Of the 13 Salem sump tubes, 9 were placed successfully on first attempt and confirmed by absence of CO2 and by air bolus and aspiration of stomach contents. ETCO2 waveforms were detected with insertion of four of the Salem sump tubes; the tubes were immediately withdrawn, and placement was reattempted until successful., Conclusions: The technique described is a simple, cost-effective method of assuring accurate gastric tube placement in critically ill patients.

Tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of Virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.

Thirty-two magnetic resonance imaging examinations of the lungs were performed in 16 subjects after inhalation of 1-2 L of helium 3 gas that was laser polarized to 10%-25%. The distribution of the gas was generally uniform, with visualization of the fissures in most cases. Ventilation defects were demonstrated in smokers and in a subject with allergies. The technique has potential for evaluating small airways disease.

Background: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation., Objective: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation., Methods: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used., Results: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group., Conclusion: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

Objective: To determine the incidence of obstruction and colonization in adult patients in the surgical and medical intensive care units who received inner cannula changes daily versus those who did not., Design: Quasi-experimental prospective study using a convenience sample of patients randomly assigned to one of two methods., Setting: Mid-Atlantic university-affiliated tertiary care center., Patients: Sixty patients within 24 hours of receiving a surgical tracheostomy., Outcome Measures: Obstruction and bacterial colonization of inner cannula., Interventions: All inner cannulas were checked daily for obstruction and cultured on postoperative days 1 and 3., Results: No statistically significant difference was noted in colonization (p = 0.13) between protocols, and no obstructions were noted in either., Conclusion: The study suggests that the routine practice in critical care units of changing tracheostomy inner cannulas may be unnecessary. Although the results of this study are limited, and may not be generalized to other populations, it demonstrates that practice standards related to the care of tracheostomy inner cannula need to be challenged.

Objective: A clinical study was undertaken to define optimal preoperative strategies and intraoperative techniques that would result in the least morbidity and maximum physiologic improvements in patients with end-stage emphysema selected for lung volume reduction surgery., Background: Lung volume reduction surgery recently has been advocated as an alternative or a bridge to lung transplantation for patients with end-stage chronic obstructive pulmonary disease. The risks, benefits, and long-term results have not been clarified., Methods: Twenty-six patients underwent lung volume reduction surgery with a 3-month follow-up on 17 patients. Preoperative and postoperative changes in pulmonary function parameters, quality of life, and oxygen requirement were analyzed. The value of preoperative localization of diseased lung segments and how this affects intraoperative resection is addressed., Results: Forty-nine percent improvement in FEV1 (forced expiratory volume in 1 second) and 23% improvement in FVC (forced vital capacity) were seen after lung volume reduction surgery. Supplemental oxygen requirement was decreased and 79% of patients reported a much better quality of life. Mortality was 3.8% and air leak morbidity was 18%., Conclusions: Lung volume reduction surgery can predictably improve objective and subjective pulmonary function in selected patients with end-stage emphysema with low morbidity and mortality. Careful patient selection, accurate preoperative localization of diseased target areas, skilled anesthetic technique, meticulous operative approach, and intense postoperative support are essential to achieve favorable results.

Background: Despite extensive data acquired in the area of weaning, clinicians still struggle with the questions of how and when to begin the process. Clinical weaning indices, designed to predict weaning potential, are often difficult to use. They provide an answer at a specific time; extrapolation to the weaning process is rarely possible. No single index has proven to be superior., Objectives: To test the efficacy of five clinical weaning indices (Burns Weaning Assessment Program; Weaning Index; frequency tidal volume ratio; compliance, resistance, oxygenation and pressure index; and negative inspiratory pressure) at regular intervals during withdrawal of ventilatory support and to determine threshold levels for the program., Methods: A prospective convenience sample consisted of 37 adult critical care patients requiring mechanical ventilation for at least 7 days and identified as stable and ready to wean. Data were collected on all weaning indices every other day until the patient was weaned., Results: With the exception of the Burns Weaning Assessment Program, weaning indices did not change significantly from preweaning scores. Furthermore, the results failed to demonstrate that any of the five clinical weaning indices have strong predictive power related to weaning trial outcomes, although all the indices had negative predictive values that may be helpful in predicting unsuccessful weaning trials., Conclusions: The results of this study suggest that the process of weaning may be enhanced by comprehensive, systematic approaches and that clinical weaning indices like the Burns Weaning Assessment Program might best serve as tools to track trends in progress, keep care planning on target, and prevent unsuccessful weaning trials.

Atelectasis is a major factor in postoperative morbidity for patients undergoing cardiopulmonary surgery. We evaluated the effectiveness of stacked inspiratory spirometry (STIS) in 17 patients status postcoronary artery bypass graft in a nonrandomized fashion. We measured pulmonary shunt as an endpoint, and compared the magnitudes before and after the STIS maneuver. Our results showed an 8.66 percent reduction in pulmonary shunt (p < 0.05). The reduction in shunt was modest; however, repetitive maneuvers might result in greater improvement.

Bedside monitoring of respiratory status is designed to measure specific parameters and alert the clinician when these parameters exceed the limits of a desired range. Parameters should include measures of respiratory mechanics, oxygenation, and ventilation. Monitoring is the only form of communication between the physician and a patient receiving neuromuscular blocking agents. Airway pressure tracing alone, or in conjunction with concurrent flow, measures respiratory system mechanics, resistance, compliance, and the work of breathing. Pulse oximetry reflects oxygenation, while mixed venous oximetry indicates the balance between oxygen supply and demand. Capnography is a noninvasive way of assessing ventilation. Taken as a whole, noninvasive monitoring provides useful information, reflecting trends in oxygenation, ventilation, and mechanics. This article reviews the concepts of noninvasive monitoring of critically ill patients. Emphasis is given to the patient receiving neuromuscular blocking agents.

Objective: This study evaluates the efficacy of personally inspecting marginal thoracic organ donors to expand the donor pool., Summary Background Data: The present donor criteria for heart and lung transplantation are very strict and result in exclusion of many potential thoracic organ donors. Due to a limited donor pool, 20-30% of patients die waiting for transplantation., Methods: The authors have performed a prospective study of personally inspecting marginal donor organs that previously would have been rejected by standard donor criteria., Results: Fourteen marginal hearts and eleven marginal lungs were inspected. All 14 marginal hearts and 10 of the marginal lungs were transplanted. All cardiac transplant patients did well. The mean ejection fraction of the donor hearts preoperatively was 39 +/- 11% (range 15-50%). Postoperatively, the ejection fraction of the donor hearts improved significantly to 55 +/- 3% (p < 0.002). Nine of the ten lung transplant patients did well and were operative survivors. Our donor pool expanded by 36% over the study period., Conclusions: The present donor criteria for heart and lung transplantation are too strict. Personal inspection of marginal thoracic donor organs will help to maximize donor utilization.

The maximal pressure that can be generated during an inspiratory effort against an occluded airway serves as an index of respiratory muscle strength. We devised a method that permits accurate measurement of MIP, with near maximal values, and does not require patient cooperation. Twenty-two critically ill intubated patients performed MIP maneuvers before and after coaching. For the initial 11 patients, MIP was measured after the airway was occluded in 20 s with a one-way valve that permitted only exhalation. In the latter 11 patients, DS (approximately 1/3 VT) was added in an effort to increase respiratory drive before the noncoached MIP maneuver. We found no significant difference between coached and noncoached MIP maneuvers when P0.1 during the first 100 ms of inspiratory efforts prior to the noncoached MIP maneuver was greater than 2 cm H2O. Thus, MIP can be reliably measured in critically ill patients with or without coaching.

We hypothesized that the ventilatory capacity needed to wean from mechanical ventilation (mv) depends on two variables: ventilatory endurance and the efficiency of gas exchange. We also hypothesized that these variables could be assessed from data readily available at the bedside, including tidal volume (VT) on mv and during spontaneous breathing (sb), ventilator peak inspiratory pressure (Ppk), and patient negative inspiratory pressure (NIP). Ventilatory endurance was evaluated using a modified pressure-time index: PTI = TI/Ttot x Pbreath/NIP, where Pbreath = Ppk x VTsb/VTmv. Defining VE40 as the minute ventilation needed to bring PaCO2 to 40 mm Hg, the efficiency of gas exchange was evaluated by calculating VE40/VTsb = (VE x PaCO2)mv/VTsb x 40. Because high levels of inspiratory effort might cause patients to reduce VTsb and thereby compromise CO2 elimination, we devised a weaning index (WI) that combines ventilatory endurance and the efficiency of gas exchange: WI = PTI x (VE40/VTsb). The study population comprised 38 patients with chronic obstructive pulmonary disease, adult respiratory distress syndrome, pneumonia, neuromuscular disease, and miscellaneous other conditions. They had been mechanically ventilated more than 3 days and were considered by clinical criteria to be ready for weaning. Of 46 weaning trials, 19 were successful, 2 were partially successful, and 25 failed. PTI and VE40/VTsb were higher in patients who failed (p less than 0.05), but neither variable alone had sufficient sensitivity or specificity to predict the outcome of weaning trials accurately.(ABSTRACT TRUNCATED AT 250 WORDS)

The critical care clinician commonly encounters patients with acute bronchospasm. Therapy includes a multidrug regimen of sympathomimetics, anticholinergics, methylxanthines, and corticosteroids. The best use of these agents is predicated on knowledge and avoidance of drug toxicities. This article reviews toxic effects of these bronchodilator agents.

Lung transplantation is now established as a clinical reality for patients with irreversible, lethal pulmonary conditions. We report the first successful application of this treatment modality in Virginia.

In recent years, four square-wave modes of pressure-preset mechanical ventilation (PPV)--pressure control, pressure support, inverse ratio, and airway pressure release ventilation--have been introduced to clinical practice. Conceptually, they share important features. Yet, because there remains widespread uncertainty regarding their ventilatory characteristics, efficacy, and appropriate use, the potential range of application is only now being investigated. To construct a unifying mathematical model of PPV, we developed a system of equations for prediction of the major "outcome" variables of PPV--tidal volume, minute ventilation, auto-positive end-expiratory pressure, mean alveolar pressure, and mechanical work--from the primary clinical "inputs" from patient (resistance, compliance) and clinician (applied pressure, frequency, inspiratory time fraction). Our analysis revealed distinct bounding limits for the outcome variables of ventilation and pressure and important implications for their clinical determinants. Although simplifying assumptions were required to enable construction of this mathematical analogue of respiratory system behavior, this model provides a firm conceptual framework for understanding the physiological interactions between PPV and the patients they are intended to help.