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Pediatric acute respiratory distress syndrome (PARDS) is a relatively common critical illness in the pediatric intensive care unit with an incidence of about 3%. It has a high mortality rate; although this number has decreased in the last de-cades, it is still as high as 18%; in some developing countries, it even reached 40%-50% in the last 2-3 years. Optimized mechanical ventilation strategy contributes to an improved prognosis. To this end, this article reviews the current status of research on mechanical ventilation strategies in PARDS.

Background At present, there are a variety of mechanical ventilation mode of breathing for premature infants with respiratory distress syndrome (NRDS) , but the application of these techniques in Tibetan Plateau are limited because of the low air pressure and oxygen content and etc. The NRDS initial breathing support measures can only be performed with INSURE technique (tracheal intubation—injection of pulmonary surfactant—nasal continuous positive airway pressure ventilation after extubation) and invasive mechanical ventilation (MV) . It is currently unclear what factors influence the selection of the NRDS initial breathing support therapy in premature infants in Tibetan Plateau. Objective To explore the factors in selection of supporting NRDS initial breathing strategies in high altitude area and evaluate the early clinical outcomes of different supporting strategies. Methods The clinical data of 183 premature infants diagnosed with NRDS and their mother's general data in Paediatri neonatal ward of Lhasa People's Hospital from June 2018 to June 2020 were analyzed retrospectively. According to the accepted initial respiratory support mode, they were divided into INSURE group (n=122) and MV group (n=61) . Multifactorial Logistic regression analysis was used to explore influencing factors in selection of NRDS initial breathing support treatment. Results The gestational age, birth weight, 1 min, 5 min and 10 min Apgar scores in MV group were lower than those in INSURE group and the proportion of prenatal application of glucocorticoids was higher than that in INSURE group (P

DOI：10.3969/j.issn.1672⁃6731.2020.08.010

Acute respiratory distress syndrome (ARDS) is one of the most common syndromes in the intensive care unit, with a high mortality and morbidity. Refractory hypoxia is the typical feature of ARDS, and improving hypoxia is the key to the treatment of ARDS. Due to the rapid progression of ARDS, invasive ventilation is usually used to improve hypoxia. But in recent years, with the extending of the understanding of ARDS and the development of non-invasive oxygen therapy, high flow nasal oxygen (HFNO) and non-invasive ventilation (NIV) are gradually used in ARDS. Therefore, we reviewed the role of HFNO and NIV in ARDS in this paper.

Prone positioning ventilation (PPV) is considered one of the essential therapeutic approaches in the management of acute respiratory distress syndrome (ARDS). Several randomized controlled clinical trials have demonstrated the efficacy of PPV in the treatment of patients with ARDS. However, it is not clear whether PPV treatment can reduce mortality in patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO)-supported ARDS and corona virus disease 2019 (COVID-19)-associated ARDS. This review aims to discuss the known and unknown aspects of the mechanism of PPV for ARDS, the clinical efficacy of PPV for ARDS, VV-ECMO-supported ARDS, and COVID-19-related ARDS.

Objective: To explore the effect of THRIVE combined with i-gel laryngeal mask on the safety of oxygen therapy in apnea and surgical precision of retrograde intrarenal surgery., Methods: A total of 120 patients undergoing retrograde intrarenal surgery under general anesthesia with laryngeal mask were randomized into 3 groups ( n =40), and after the flexible ureteroscope entered the renal pelvis and located the stones, the patients received assisted ventilation in APPV mode (control group), ventilation with small tidal volume and high respiratory rate (group H), or THRIVE combined with laryngeal mask for oxygen supply without using the ventilator (THRIVE group). The time for lithotripsy by the surgeons, surgeons' satisfaction, diaphragm mobility, and times of urinary tract mucosal injury were recorded, and arterial blood pressure, heart rate, SpO 2 , PaO 2 , PaCO 2 , and pH value were measured before, during and after lithotripsy., Results: Among the 3 groups, THRIVE group had the shortest time for lithotripsy, best satisfaction of the surgeons, the lowest diaphragmatic mobility of the patients, and the smallest number of mucosal injuries. The arterial blood pressure, heart rate, and SpO 2 of the patients did not differ significantly among the 3 groups. At 20 min and 30 min after the start of lithotripsy, PaO 2 decreased significantly in group H and THRIVE group; in THRIVE group, PaCO 2 increased and pH decreased significantly at 10, 20 and 30 min after the start of lithotripsy. No significant difference was found in oxygenation indicators among the 3 groups upon discharge from the PACU., Conclusion: In retrograde intrarenal surgery, THRIVE combined with i- gel laryngeal mask for oxygen therapy during the anaerobic period can improve the surgical accuracy and maintain the patient's oxygenation index in a controllable range within 30 min.

Objective: To explore the impact of a new type of modified nasopharynx airway preserving spontaneous breathing under general anesthesia on the postoperative recovery quality of patients undergoing hysteroscopic daytime surgery. Methods: A total of 80 patients undergoing hysteroscopic daytime surgery at Beijing Tongren Hospital from August to December 2022 was prospectively selected. The patients were randomly divided into two groups using a random number table method: patients in the laryngeal mask mechanical ventilation general anesthesia group (laryngeal mask group, n =40) aged (46.8±10.1) years (20-65 years), while patients in the modified nasopharyngeal airway preserving spontaneous breathing general anesthesia group (nasopharyngeal airway group, n =40) aged (45.5±12.1) years (26-65 years). The main outcome measures were the clinical recovery score (CRS) and modified alertness and sedation score (MOAA/S) of patients at different postoperative time points. Secondary observation indicators included anesthesia induction time, awakening time, and extubation time, changes of hemodynamic indicators between preoperative and intraoperative period, and incidence of adverse reactions during and after surgery. Results: The CRS scores [ M ( Q 1 , Q 3 )] of patients in the nasopharyngeal airway group were 8 (8, 9), 8 (8, 9), 8 (8, 9), 9 (9, 9) and 10 (10, 11) at postoperative awakening, immediately after extubation, 5 minutes after extubation, 15 minutes after extubation, and 30 minutes after extubation, respectively, which were higher than those in the laryngeal mask group [7 (6, 8), 7 (7, 8), 7 (7, 8), 8 (8, 8) and 9 (8, 9)] (all P <0.001). The MOAA/S scores of the nasopharyngeal airway group were 5 (5, 5), 5 (5, 5), 5 (5, 5) and 5 (5, 5) at postoperative awakening, immediately after extubation, 5 minutes after extubation, and 15 minutes after extubation, respectively, which were higher than those in the laryngeal mask group [4 (3, 5), 4 (4, 5), 5 (5, 5) and 5 (5, 5)] (all P <0.05). The anesthesia induction time, awakening time, and extubation time of the nasopharyngeal airway group were (47.8±4.3) s, (4.1±1.7) min and (4.5±1.7) min, respectively, which were shorter than those of laryngeal mask group [(138.8±4.2) s, (7.2±2.9) min and (8.1±2.7) min] (all P <0.05). The mean arterial pressure (MAP) of patients in the nasopharynx airway group during extubation was (84.9±10.2) mmHg (1 mmHg=0.133 kPa), which was lower than that of the laryngeal mask group [(93.2±7.5) mmHg] ( P <0.05). The partial pressure of end-tidal carbon dioxide (PetCO 2 ) during cervical dilation was (22.0±5.9) mmHg, which was lower than those of the laryngeal mask group [(37.2±2.2) mmHg] ( P <0.05). The PetCO 2 during intrauterine operation and extubation were (45.5±6.7) and (41.6±4.5) mmHg, which were higher than those of the laryngeal mask group [(39.2±4.1) mmHg and (38.6±3.6) mmHg] (both P <0.05). The incidence of respiratory depression and body movement during surgery in the nasopharyngeal airway group were 27.5% (11/40) and 17.5% (7/40), respectively, which were higher than those in the laryngeal mask group [0 and 0] (both P <0.05). The incidence of postoperative drowsiness was 2.5% (1/40), which was lower than that of the laryngeal mask group [17.5% (7/40)] ( P <0.05). There was no severe physical activity or intraoperative awareness in the two groups. Conclusion: The new modified general anesthesia method of preserving spontaneous breathing through the nasopharynx airway can improve the postoperative recovery quality of patients, and reduce the occurrence of adverse reactions, which facilitates rapid recovery after hysteroscopic daytime surgery.

The mortality of acute respiratory distress syndrome (ARDS) patients is very high, veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been proved to improve the prognosis of these patients, but the maximization of this benefit relies on the appropriate mechanical ventilation strategy; with the new research evidence arise, scholars have reached a certain consensus on how to implement mechanical ventilation in ARDS patients supported by VV-ECMO, but there are still many controversies. Based on the evidences of current researches and clinical experiences, this article analyzes the hot issues of mechanical ventilation strategy for these patients, including the implementation of early 'overprotective' ventilation strategy, whether spontaneous breathing allowed, prone ventilation and ventilator weaning.

This paper introduced several problems of long-term oxygen therapy in chronic obstructive pulmonary disease (COPD) patients, including basic concepts, research progress at home and abroad, physiological significance of long-term oxygen therapy, clinical indications, contraindications, long-term oxygen therapy under special conditions, oxygen source, connection mode, inhaled oxygen concentration management, airway humidification, cooperation and safety of non-invasive ventilation.

Objective: To evaluate the efficacy of two-lung ventilation with different tidal volume assisted by CO 2 pneumothorax for airway management in patients undergoing radical esophagectomy using combined thoracoscopic and laparoscopic approach. Methods: One hundred and eighty patients undergoing radical esophagectomy using combined thoracoscopy and laparoscopy under general anesthesia from the Affiliated Cancer Hospital of Zhengzhou University between February and September 2019 were randomly divided into three groups (group V 1 , V 2 , V 3 , n =60) according to the tidal volume (TV) used. The TVs of group V 1 -V 3 were 4, 5, 7 ml/kg during thoracoscopic surgery, respectively. All the patients were intubated with a single-lumen endotracheal tube and underwent two-lung ventilation assisted by continuous positive pressure CO 2 pneumothorax in group V 1 , V 2 and V 3 , with the CO 2 pressure of 10 mmHg (1 mmHg=0.133 kPa) and the frequency of 20 times/min. Mean arterial pressure (MAP) and heart rate (HR) were recorded before thoracoscopic surgery (T 1 ), 30 minutes after thoracoscopic surgery (T 2 ), at the end of thoracoscopic surgery (T 3 ), after thoracoscopic surgery and 30 minutes after two-lung intermittent positive pressure ventilation, respectively. The results of arterial blood gas were collected at T 1 , T 2 , T 3 and T 4 . Recovery time from anesthesia, consciousness recovery time, and lung collapse condition were recorded. Results: At T 2 , the value of MAP in group V 1 was (81±10) mmHg, which was higher than those of group V 2 [(69±7) mmHg] and group V 3 [(71±8) mmHg], with a statistically significant difference ( F= 9.270, P <0.05). Meanwhile, at T 2 , the value of HR in group V 1 was (83±7) times/min, which was higher than those of group V 2 [(68±6) times/min] and group V 3 [(71±7) times/min], and there was a statistically significant difference ( F =23.460, P <0.05). However, at T 2 , the values of arterial partial pressure of oxygen (PaO 2 ) in three groups were (262±16), (249±16) and (241±20) mmHg, respectively, with no statistically significant difference ( F =1.929, P >0.05). At T 3 , the value of arterial partial pressure of carbon dioxide (PaCO 2 ) in group V 3 was (46±5) mmHg, which was lower than those of group V 1 [(63±9) mmHg] and V 2 [(62±10) mmHg], with a statistically significant difference ( F =20.890, P <0.05). Moreover, at T 3 , the value of pH in group V 3 was (7.35±0.04), which was higher than those of group V 1 (7.28±0.04) and V 2 (7.32±0.04), and there was a statistically significant difference ( F= 9.309, P <0.05). Additionally, the satisfaction rates of lung collapse in group V 3 was 57.1%, which was lower than those of group V 1 (94.7%) and group V 2 (96.3%), with a statistically significant difference (χ²=7.601, P <0.05). There was no statistical significance in the time of awakening and consciousness recovery among three groups ( F =1.020 and 1.110, both P> 0.05). Conclusion: The two-lung ventilation with 5 ml/kg tidal volume assisted by CO 2 pneumothorax has advantages in terms of hemodynamics and surgical field exposure, and is more suitable as the appropriate dose for respiratory management in patients undergoing radical resection of esophageal cancer using combined thoracoscopic and laparoscopic approach.

Objective: To investigate the effects of restrictive fluid management in patients with severe traumatic brain injury (sTBI)., Methods: Between January, 2019 and June, 2020, we randomly assigned 51 postoperative patients (stay in the ICU of no less than 7 days) with sTBI into treatment group ( n =25) with restrictive fluid management and the control group ( n =26) with conventional fluid management. The data of optic nerve sheath diameter (ONSD), middle cerebral artery pulsatility index (MAC- PI), neuron-specific enolase (NSE) level, inferior vena cava (IVC) diameter, Glascow Coma Scale (GCS) score, mean arterial blood pressure, heart rate, and fluid balance of the patients were collected at ICU admission and at 1, 3 and 7 days after ICU admission, and the duration of mechanical ventilation, ICU stay, and 28-day mortality were recorded., Results: The cumulative fluid balance of the two groups were positive on day 1 and negative on days 3 and 7 after ICU admission; at the same time points, the patients in the treatment group had significantly greater negative fluid balance than those in the control group ( P < 0.05). In both of the groups, the ONSD and MCA-PI values were significantly higher on day 1 than the baseline ( P < 0.05), reached the peak levels on day 3, and decreased on day 7; at the same time point, these values were significantly lower in the treatment group than in the control group ( P < 0.05). No significant difference was found in NSE level on day 1 between the two groups ( P >0.05); on day 3, NSE level reached the peak level and was significantly higher in the control group ( P < 0.05); on day 7, NSE level was lowered the level of day 1 in the treatment group but remained higher than day 1 level in the control group. The 28-day mortality rate did not differ significantly between the two groups (16.00% vs 23.08%, P >0.05); the duration of mechanical ventilation, length of ICU stay, and the number of tracheotomy were all significantly shorter or lower in the treatment group than in the control group ( P < 0.05)., Conclusions: Restrictive fluid management can reduce cerebral edema and improve the prognosis but does not affect the 28-day mortality of patients with sTBI.

Objective: To investigate the value of non-invasive ventilation (NIV) combined with high flow nasal cannula oxygen therapy (HFNCO) in sequential treatment of patients with chronic obstructive pulmonary disease after mechanical ventilation. Methods: Chronic obstructive pulmonary disease with acute exacerbation (AECOPD) patients with invasive mechanical ventilation (MV) and successful withdrawal admitted into Huxi Affiliated Hospital of Jining Medical College from January 2018 to December 2019 were enrolled for perspective study. The patients were divided into treatment group ( n= 40) and control group ( n= 33) by random number table method. The treatment group was given NIV and HFNCO, the control group was given NIV treatment alone. Bedside ultrasound was used to measure the patients' diaphragmatic motion, and the differences between the two groups of patients before treatment, 24, 48 and 72 h after treatment were compared in diaphragmatic excursions during quiet breathing (DEq), diaphragmatic excursions during deep breathing(DEd), diaphragmatic shallow fast breathing index (D-RSBI), arterial oxygen partial pressure (PaO(2)), arterial partial pressure of carbon dioxide (PaCO(2)), re-tracheal intubation rate, mortality rate for 28 days and average duration of NPPV treatment within 3 days. Results: There were no statistically significant differences in DEq, DEd, D-RSBI, PaO(2) and PaCO(2) between the two groups before treatment (all P> 0.05). After 24 h treatment, DEd decreased in both groups, D-RSBI increased in both groups, However, D-RSBI [(1.33±0.56) vs (1.62±0.59) times·min(-1)·mm(-1)] in the treatment group was significantly lower than the control group, P= 0.034. After 72 h treatment, DEd [(41.4±8.1) vs (37.8±6.0) mm] was significantly higher than the control group, D-RSBI [(1.02±0.27) vs (1.22±0.43) times·min(-1)·mm(-1)] was significantly lower than the control group (all P< 0.05). The average duration of NIV treatment time [(7.5±1.2) vs (9.3±2.6) h] in the treatment group was significantly shorter than that in the control group ( P< 0.01). There were no statistically significant differences in PaO(2), PCO(2), re-tracheal intubation rate and the mortality rate of 28 days. Conclusion: NIV combined with HFNCO sequential therapy can effectively relieve diaphragm fatigue and promote recovery of respiratory muscle strength, and it's better than NIV alone.

Objective: To observe the effect of different modes of mechanical ventilation on patient-ventilator synchrony and diaphragm function in rabbits with acute respiratory distress syndrome(ARDS). Methods: Eighteen New Zealand rabbit models of ARDS were induced by intratracheal infusion hydrochloric acid until the oxygenation index (PaO(2)/FiO(2)) was less than 200 mmHg, and then divided into three groups with random number: assisted-controlled mechanical ventilation (A/C) group, pressure support ventilation (PSV) group and neurally adjusted ventilatory assist (NAVA) group. All of them were ventilated for four hours with the targeted tidal volume (V(T)) (6 ml/kg) and the positive end-expiratory pressure (PEEP) titrated with the maximum oxygenation method. Gas exchange, pulmonary mechanics and patient-ventilator synchrony were determined during 4 h of ventilation and the concentrations of malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione (GSH) in diaphragm were measured after 4 h of ventilation. The q test was used for the multiple comparison of the sample mean. Results: There were no significant differences in PaO(2)/FiO(2) between three groups during ventilation 1-4 h ( F= 1.029, P> 0.05). The V(T) in NAVA group was obviously lower than that in PSV group and the respiratory rate (RR) and the electrical activity of diaphragm(EAdi) were higher than those in A/C group(all P< 0.05).The trigger delay and off cycle delay the in NAVA group were markedly lower than those in A/C and PSV group during ventilation 1-4 h( F= 14.312, 9.342, both P< 0.05). Asynchrony index in NAVA group (3.1%±1.0%) was obviously lower than those in A/C group (22.3%±5.2%) and PSV group(8.4%±2.3%) ( F= 7.192, P< 0.05). In NAVA group, peak EAdi (EAdi(peak)) and peak airway pressure (Ppeak) were markedly correlated ( r= 0.97±0.16, P< 0.05), while Ppeak delivery in A/C and PSV group was not correlated to EAdi(peak) ( r= 0.38±0.13,0.46±0.15, both P> 0.05).Compared with A/C group, the concentration of MDA in the diaphragm in NAVA group was obviously lower( P< 0.05). SOD and GSH level inthe diaphragm in NAVA group were both obviously higher than those in A/C group (both P< 0.05). Conclusions: It is helpful to avoid eccentric contraction of diaphragm, lessen oxidative stress and alleviate ventilator-related diaphragm dysfunction by keeping spontaneous breathing as far as possible and subject-ventilator synchrony when ventilation in ARDS with NAVA.

Objective: To set up a prediction scoring system for the hypoxemia in infants with Pierre Robin sequence after weaning and evaluate its clinical value. Methods: Data of consecutive patients from November 2016 to June 2019, who underwent mandibular distraction osteogenesis in Guangzhou Women and Children's Medical Center, were retrospectively analyzed ( n= 148). All the cases were divided into two groups according to the appearance of hypoxemia after weaning. They were randomly divided into the derivation cohorc (2/3, n= 100) and the validation cohort (1/3, n= 48). Single factor and multiple logistic regression analysis were used to select the independent risk factors related to hypoxemia and establish a prediction model. A prediction scoring system was developed in accordance with assigning of the value of each variable β in the model. Internal verification of scoring system by validation population. Data of consecutive patients from July 2019 to November 2019, who underwent mandibular distraction osteogenesis, were prospectively analyzed ( n= 26). The diagnostic accuracy were conducted to evaluate the clinical value of the scoring system. Results: The logistic regression demonstrated that age at operation, pulmonary infection and the length of distraction less than 5 mm at weaning were the independent risk factors for hypoxemia. The P value of logistic regression model in Hosmer and Lemeshow goodness of fit test was 0.848, and a prediction scoring system was established accordingly. The area under the ROC curve of the scoring system was 0.890, and the optimum critical value was 53. The sensitivity, specificity, accuracy of the model were 78.6%(11/14),86.1%(74/86), 85.0%(85/100) respectively. The predictive effectiveness of the scoring system in the retrospective validation population was similar to that in the modeling population. 26 patients were included in the prospective analysis. The area under ROC curve of the scoring system was 0.870. The sensitivity, specificity and accuracy were 80.0%(5/6),95.0%(20/21), 96.1%(25/26) respectively. Conclusion: The prediction scoring system established in the study are efficacious for the hypoxemia in infants with Pierre Robin sequence after weaning.

Objective: To investigate the therapeutic effect and safety of early physical therapy for acute gastrointestinal injury (AGI) in septic patients receiving mechanical ventilation., Methods: A randomized controlled trial was conducted in the ICU of a tertiary teaching hospital from May, 2017 to March, 2018. The patients diagnosed with sepsis complicated by AGI during mechanical ventilation were recruited and block-randomized into intervention group and control group. Both groups received standard therapy of sepsis, and the patients in the intervention group also received physical therapy as soon as they were hemodynamically stable. The outcome measures included the recovery of AGI, ICU mortality, duration and outcomes of mechanical ventilation and the length of ICU stay., Results: A total of 60 patients were initially included, and 34 of them completed the study, including 16 in the intervention group and 18 in the control group. After physical rehabilitation, the number of patients with a cure of AGI did not significantly differ between the two group ( P > 0.05). Nonetheless, the reduction of AGI scores after the treatments differed significantly between the intervention group and the control group (-1.9±2.1 vs 0.9± 1.6, P < 0.05). No significant differences were found between the two groups in ICU mortality, duration and outcomes of mechanical ventilation, or the length of ICU stay ( P > 0.05). In the intervention group, the incidence of exercise-related adverse events was 3.33%, and severe organ injury or death occurred in none of patients., Conclusions: Early rehabilitation therapy does not reduce the incidence of AGI but can lower AGI scores and alleviate gastrointestinal symptoms in patients with sepsis during mechanical ventilation. The results still await further verification by welldesigned multicenter clinical trials with large sample sizes.

Objective: To evaluate the feasibility and safety of supraglottic tracheal tube ventilation by comparing with modified laryngeal mask airway ventilation during painless fiberbronchoscopy. Methods: This was a prospective study. Twenty-eight patients undergoing painless fiberbronchoscopy in Hangzhou First People's Hospital were randomly divided into 2 groups( n =14): supraglottic tracheal tube ventilation(group A) and modified laryngeal mask airway(group B). MAP, HR, SpO(2), P(ET)CO(2) and BIS were recorded after entering the operating room(T(0)), after anesthesia induction(T(1)), immediately after inserting laryngeal mask airway or tracheal tube(T(2)), fiberbronchoscopy inserting(T(3)), at the end of the operation(T(4)), and at the recovery of patients' consciousness(T(5)). The arterial carbon dioxide partial pressure(PaCO(2)), the time spent in successful positioning of the tube, the endoscope indwelling duration, operative time, tube drawing time, patients' awakening time, satisfaction of operators, adverse events during anesthesia, the numbers of bucking or body moving were also recorded.The dose of propofol and remifentanil were also statisticed. Results: P(ET)CO(2) in group A at T(0), T(1), T(2), T(3), T(4), T(5) were (36.9±4.1), (36.3±4.7), (38.1±5.6), (40.4±4.0), (48.8±7.7), (45.3±7.6) mmHg, P(ET)CO(2) in group B were (38.6±4.4), (37.8±5.6), (37.8±5.4), (37.4±6.7), (43.3±12.2), (43.5±8.0) mmHg, at the end of operation, the P(ET)CO(2) at T(4) and T(5) were significantly higher than at T(0) in group A and group B ( F =14.582, 12.651, all P <0.05). The PaCO(2) in group A was (62.0±4.7) mmHg , which was significantly higher than group B at the end of operation[(51.9±4.2) mmHg, t =2.432, P <0.05]. The time spent successfully positioning the insertion in group A and group B were (17.6±7.5), (29.8±13.6)s, the endoscope indwelling duration were(0.8±0.1), (1.4±0.3)min, and the operation time were(32.3±4.3), (46.8±4.8)min, there were significantly difference between group A and group B( t =2.670, 2.214, 2.166, all P <0.05). There were no significantly difference of the numbers of bucking or body moving , the satisfaction of operators and patients, and adverse events (all P >0.05). Conclusion: Supraglottic tracheal tube ventilation for painless fiberbronchoscopy is a safe and effective procedure.

Objective: To explore whether cephalic artery peak velocity variation during passive leg raising (ΔVpeak(CA)-PLR) could effectively predict fluid responsiveness in mechanically ventilated severe sepsis patients with spontaneous breathing. Methods: Total of 38 patients on mechanical ventilation with spontaneous breathing admitted to the Fourth Departments of Intensive Care Unit (ICU) of Fujian Provincial Hospital from January to December in 2017 were enrolled.The patients were diagnosed with severe sepsis or sepsis shock.The peak velocity in cephalic artery (Vpeak(CA)) during PLR was measured by bedside portable ultrasonic, and then ΔVpeak(CA)-PLR was calculated.All patients received volume expansion (VE) test and the changes of stroke volume during VE test (ΔSV-VE) were measured.Patients were classified as responsive group or non-responsive group according to the ΔSV-VE increased ≥15% or not after VE test.Furthermore, the sensitivity and specificity of ΔVpeak(CA)-PLR for predicting fluid responsiveness were evaluated by receiver operating characteristic (ROC) curve.The comparisons between groups were performed with Student's unpaired two-tailed t test, and Pearson's test was used for the correlation analysis. Results: Among the patients, 22 cases responded to VE test and the rest 16 cases did not.There were no significantly differences in age, gender, body mass index, infection site, sepsis-related organ failure assessment score, acute physiology and chronic health evaluation Ⅱ score, ventilator parameters and dose of vasoactive agent between the two groups.The ΔVpeak(CA)-PLR in responsive group was markedly higher than that in non-responsive group (15.7%±4.2% vs 6.9%±4.3%, t =6.240, P <0.05), and the ΔVpeak(CA)-PLR in the responsive group was positively related to the ΔSV-VE ( r =0.723, P <0.05). Furthermore, the area of ΔVpeak(CA)-PLR under ROC curve was 0.912.The sensitivity and specificity of ΔVpeak(CA)-PLR≥12.2% to predict fluid responsiveness in the patients with sepsis were 81.8% and 87.5%, respectively. Conclusion: ΔVpeak(CA)-PLR measured by bedside portable ultrasonic can predict the fluid responsiveness in mechanically ventilated severe sepsis patients with spontaneous breathing, and it can be used to guide further fluid resuscitation.

Objective: To evaluate the efficacy of endotracheal tube for drug injection in postoperative ICU patients. Methods: A total of 60 ICU patients who were given mechanical ventilation after surgical treatment were enrolled in this study from January 2015 to August 2016 at our hospital. All the patients were divided into the observation group (30 cases) and the control group (30 cases). In the observation group, the patients were treated with the endotracheal tube for surface anesthesia by injecting 2% lidocaine into the trachea, and patients in the control group were treated with saline instead of lidocaine. Patients' tolerance to endotracheal tube, cardiovascular system adverse reactions, the frequency and dosage of sedative and analgesic drug within 12 h mechanical ventilation post operation were analyzed and compared between the two groups. Results: The occurrence rate of cough, hypertension and tachycardia in the observation group were(0.6±0.3), (0.8±0.3)and(1.3±0.6), respectively, which were significantly lower than the control group (5.9±2.1), (6.0±1.9)and(4.9±1.8), the differences were statistically significant ( P <0.05). In addition, the frequency of sedative drug was (0.8±0.3), with a dosage of midazolam(1.2±0.3)mg. While in the control group, the frequency of sedative drugs was (5.1±1.9), with a dosage of midazolam (9.9±3.2) mg. The frequency and dosage of sedative drug administration in the observation group were significantly lower than those in the control group, the difference was significant difference ( P <0.05). Conclusions: The use of endotracheal tube for drug injection can improve the tolerance of ICU patients to endotracheal tube, reduce the dosage of sedative drugs, and reduce the adverse cardiovascular reactions.

Objective: To explore the impact of antifungal therapy in mechanically ventilated patients with Candida spp. colonization in lower respiratory tract. Methods: In this retrospective study, patients required mechanical ventilation with pulmonary Candida spp. colonization admitted into the intensive care unit (ICU) between July 2012 and June 2016 were included. The patients were divided into the treatment group and control group according to whether or not they received antifungal therapy. The isolation rate of multidrug-resistant (MDR) bacteria, the incidence of ventilator-associated pneumonia (VAP), duration of mechanical ventilation, length of ICU stay, total length of hospital stay, the 28-day mortality and the overall mortality were compared between the two groups. Results: Totally, 101 patients were studied. The number of cases in treatment group was 56 and the control group was 45. The treatment group had a lower incidence of MDR bacteria isolation rate and VAP compared with the control group (16.1% vs 33.3%, 5.4% vs 17.8% respectively, both P <0.05). There were significant differences in the duration of mechanical ventilation [(17.3±5.7) days vs (22.5±7.2) days, P <0.05], length of ICU stay [(23.3±5.6) days vs (28.7 ±4.8) days, P <0.05] and the average length of hospital stay [(36.2±8.7) days vs (43.6±9.0) days, P <0.05)] in the treatment group compared with the control group. There were no statistical difference between the two groups in the 28-day mortality and the overall mortality. Conclusion: Treatment of respiratory Candida spp. colonization in mechanically ventilated patients may reduce isolation rate of MDR bacteria, the incidence of VAP, duration of mechanical ventilation, length of ICU stay and total length of hospital stay.

Objective: To investigate the feasibility of utilizing the current acute gastrointestinal injury(AGI) grading system, and explore the association of severity of AGI grade with clinical outcome in critically ill patients. Methods: The adult patients from 14 general ICUs in Zhejiang Province with an expected admission to ICU for at least 24 h were recruited, and all clinical, laboratory, and survival data were prospectively collected. The AGI grade was daily assessed based on GIsymptoms, feeding details and organ dysfunctionon the first week of admission to ICU.The intra-abdominal pressures(IAP) was measured using AbViser device. Results: Of 550 patients enrolled, mean values for age and APACHE Ⅱ score were (64.9±17.2) years and (19.5±7.4), respectively. 456 patients(82.9%) took mechanical ventilation, and 470 patients were identified for AGI. The distribution of AGI grade on the frist day of ICU admission were 50.6%(Ⅰ grade, n =238), 34.2%(Ⅱ grade, n =161), 12.4%(Ⅲ grade, n =58) and 2.8%(Ⅳ, n =13), respectively, while the distribution of the global AGI grade based on the 7-day AGI assessment of ICU admission were 24.5%(Ⅰ grade, n =115), 49.4%(Ⅱ grade, n =232), 20.6%(Ⅲ grade, n =97) and 5.5%(Ⅳ, n =26), respectively. 28- and 60-day mortality rate was 29.3%( n =161) and 32.5%( n =179), respectively. The patients with AGI had a higher 28-(31.1% vs 18.8%, P =0.025) and 60-day survival rate(34.7% vs 20.0%, P =0.01) than those with non-AGI, and also there were positive correlations between AGI grade and 28- and 60-day mortality( P <0.001). Univariate Cox regression analysis showed that age, the source of medicial admission, diabetes mellitus, coronary heart disease, the use of vasoactive drugs, serum creatinine and lactate, mechanical ventilation, APACHE Ⅱ score, the AGI grade in the first day of ICU admission and feeding intolerance within the first week of ICU stay were significantly( P ≤0.02) associated with mortality. In multivariate analysis including all these variables, the source of medical admission(χ(2)=4.34, P =0.04), diabete mellitus(χ(2)=3.96, P =0.05), the use of vasoactive drugs(χ(2)=6.55, P =0.01), serum lactate(χ(2)=4.73, P =0.03), the global AGI grade in the 7-day of ICU admission(χ(2)=7.10, P =0.008), and APACHE Ⅱ score(χ(2)=12.1, P <0.001) remained independent predictors for 60-day mortality.In the further subgroup analysis including 402 patients with 7-day survival, the feeding intolerance within the first week of ICU stay could provide independent and incremental prognostic value of 60-day mortality wtih increased χ(2)value of Cox regression model(χ(2)=52.2 vs 41.9, P =0.007) . Conclusion: The AGI grading system is useful for identifying the severity of gastrointestinal dysfunction, and could be used as a strong predictor of impaired outcome. The results provide evidence to support that feeding intolerance within 7 days of admission to ICU was an independent determinant of mortality.

Objective: To explore the clinical characteristics and long-term outcomes of mechanically ventilated patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. Methods: In this observational study, patients with anti-NMDAR encephalitis were enrolled, who were admitted into Xuanwu Hospital of Capital Medical University from Jan 2012 to Jun 2015.All patients accepted tumor screening, symptomatic therapy, and immunotherapy.Outcomes were assessed by modified Rankin Scale (mRS) after immunotherapy every 6 months, and mRS 0-2 was defined as favorable outcome.The differences of clinical manifestations, auxiliary examinations, and outcomes between mechanical ventilation (MV) group and no MV group were analyzed. Results: Fifty-six patients (mean age 28±12 years, range 12 to 58 years) were enrolled, and 28 were male.MV group included 16 (28.6%) patients.Five female patients were diagnosed with ovarian teratoma.After 6 months, 50 patients (89.3%) had favorable outcomes, mortality was 0.The proportions of patients being female, with ovarian teratoma, conscious disturbance, dysautonomia, accepting plasmapheresis, immunodepressant treatment, admitted into neuro-critical care unit in MV group were significant higher than those in no MV group.The duration of illness prior to MV was 10-73 days (mean 33±19 days). The period of MV was 3-154 days (mean 46±41 days). There was no significant difference in the period of using MV among different outcome groups.After 6-48 months' follow-up, 6 patients (10.7%) relapsed, with 1 patient in MV group (1/16, 6.3%), 5 patients in no MV group (5/40, 12.5%). The relapses and long-term outcomes were not significant different between MV group and no MV group. Conclusions: The condition of mechanically ventilated patients with Anti-NMDAR encephalitis is severe, and the treatment is difficult. However, after active combined immunotherapy and life support, majority of these patients could get good long-term outcomes.

Objective: To investigate the predictive value of early lactate area for mortality in elderly patients with septic shock. Methods: From January 2012 to December 2013, a prospective study was conducted in the Department of Critical Care Medicine, Qilu Hospital of Shandong University. A total of 115 septic shock patients with age ≥65 years were included in the study. Serum lactate was measured every 6 hours, the lactate indicators, including early lactate area, APACHE Ⅱ score etc were recorded. Results: The overall 28-day mortality rate was 67.0%. The top three primary infection sources were lung, abdominal cavity and bloodstream. When compared to survivors, non-survivors had significantly elevated early lactate area and APACHE Ⅱ score and lowered lactate clearance[(27.4±7.6) vs ( 20.3±6.5)], they were significantly more likely to have undergone mechanical ventilation, renal replacement therapy and inotropic or vasopressor support for ≥3 d, and more frequently displayed signs of cardiovascular, respiratory, and renal and hepatic dysfunction (all P <0.05) .Receiver Operating Characteristic curves indicated the lactate area score displayed a strong predictive power for 28 day mortality as indicated by an AUC of 0.758 ( P <0.01) and had significantly greater predictive power when compared to the initial lactate or lactate clearance (all P <0.05). Conclusions: In geriatric patients with septic shock, the early lactate area is a useful predictor for early death and showed better predictive value than other lactate indicators.

Objective: To investigate the factors associated with positive results of blood culture and the impact of positive results on the prognosis of patients in ICU of Peking University People's Hospital., Methods: We retrospectively analyzed 1 008 blood culture results of 379 critical ill adult patients in ICU from July 1st, 2013 to June 30th, 2014. According to blood culture results, the patients were divided into positive and negative groups. The patients' maximal body temperature, sample collection times, number of bottles within 24 hours, routine hematological variables [(white blood cell count (WBC), percentage of neutrophils (NEU%), lymphocyte count (LYM), platelet count (PLT)], serum C-reactive protein (CRP), usage of antibiotics were compared between the two groups, as well as the patients' gender, age, duration of mechanical ventilation, length of ICU stay and hospital mortality rate., Results: The total positiverate of blood culture of our study was 15.38%, and the positive rate of patients was 24.27%.When compared between positive group and negative group, the medians of sample collection times were 3 and 1(P<0.000 1); the medians of sample bottles were 4 and 4(P=0.001 2); the medians of WBC were 8.61×10(9)/L and 9.95×10(9)/L(P=0.001 7); and the medians of mechanical ventilation time were 179.5 hours and 47 hours(P<0.000 1); the medians of length of ICU stay were 17 days and 7 days(P<0.000 1), respectively. Hospital mortality rates in positive patients and negative patients were 35.87% and 20.21%(P=0.002 2), respectively. There was no significant difference(P>0.05) between the two groups in body temperature, NEU%, LYM, PLT, CRP or usage of antibiotics., Conclusions: Increasing the frequency of sampling and the bottles of blood culture will improve the positive rate of blood culture. The body temperature, WBC, NEU%, LYM, PLT, CRP, us age of antibiotics, gender and age have no effect on the positive rate of blood culture. The patients with positive blood culture results have longer duration of mechanical ventilation, longer ICU stayand higher hospital mortality rate.

Objective: To evaluated the 3 sedation regimen for patients with septic shock., Methods: The randomized controlled trial wan conducted. Forty-five patients with septic shock were assigned to 3 groups (midazolam group, propofol group, and dexmedetomidine group) randomly. The basic characteristics of patients, the duration of mechanical ventilation, the length of stay in the ICU, the death rate for 28 days and the regulatory cell (Treg) in peripheral blood were observed. The control group for Treg test was consisted of 20 healthy volunteers., Results: There were no significant differences between the groups in the death rate for 28 days and the duration of mechanical ventilation. The length of stay in the ICU in dexmedetomidine group was shorter than that in midazolam group(15.21±5.55 vs.19.67±5.7 days, P<0.05). The Treg of 3 groups was higher than that of control group (11.82±4.93 vs.3.69±1.71, 11.30±3.42 vs. 3.69±1.71, 12.83±6.17 vs. 3.69±1.71) at the first day of ICU. The Treg after 3 ICU days in dexmedetomidine group and the Treg after 5 ICU days in propofol group and in midazolam group have no difference with control group., Conclusion: For the patients with septic shock, dexmedetomidine could decrease the length of stay in the ICU and the duration of immune suppression.

Objective: To investigate effect of lung protective ventilation on respiration and circulation in elderly patients receiving spinal operation performed in the prone position., Methods: Sixty patients undergoing elective spinal surgery were randomized control group [with VT of 10 mL/kg (PBW) and RR of 10-12 /min] and test group [with VT of 6 mL/kg +RMs+PEEP: 5 cmH(2)O (PBW) and RR of 12-18 /min]. Recruitment maneuver was performed once every 30 min. HR, MAP, P(peak), P(Plat), PaO(2)/FiO(2), SpO(2), PaCO(2), WBC, NEUT%, CRP, VAS, pulmonary complications risk score, and clinical pulmonary infection score were recorded before the operation, upon entry in the operation room, at 5 min before and 30 min, 1 h, and 3 h after changing into the prone position, and at 1 day and 3 days after the operation., Results: Pulmonary complications risk score, HR, MAP, WBC, NEUT%, and PaCO(2) were all comparable between the two groups (P>0.05). P(peak) and P(plat) of the test group were lower than those of the control group after entering the operation room and at 5 min before and 30 min, 1 h, and 3 h after changing into the prone position (P<0.05). Compared with those in the control group, the oxygenation index at 1 day after the operation was significantly higher and CRP and postoperative clinical pulmonary infection score at 1 day and 3 days after the operation were significantly lower in the test group (P<0.05)., Conclusions: Lung protective ventilation can reduce the risk of barotrauma, reduce lung inflammation, and improve postoperative oxygenation in elderly patients undergoing spinal surgery in the prone position without affecting intraoperative hemodynamics or causing CO(2) retention.

Objective: To investigate the effect of losartan in regulating oxidative stress and the underlying mechanism in mice with ventilator-induced lung injury., Methods: Thirty-six male C57 mice were randomly divided into control group, losartan treatment group, mechanical ventilation model group, and ventilation plus losartan treatment group. After the corresponding treatments, the lung injuries in each group were examined and the expressions of caveolin-1 and NOX4 in the lung tissues were detected., Results: The mean Smith score of lung injury was significantly higher in mechanical ventilation model group (3.3) than in the control group (0.4), and losartan treatment group (0.3); the mean score was significantly lowered in ventilation plus losartan treatment group (2.3) compared with that in the model group (P<0.05). The expressions of caveolin-1 and NOX4 were significantly higher in the model group than in the control and losartan treatment groups (P<0.05) but was obviously lowered after losartan treatment (P<0.05). Co-expression of caveolin-1 and NOX4 in the lungs was observed in the model group, and was significantly decreased after losartan treatment., Conclusion: Losartan can alleviate ventilator-induced lung injury in mice and inhibit the expression of caveolin-1 and NOX4 and their interaction in the lungs.

Objective: To investigate the pulmonary ultrasound in children with congenital heart disease postoperative invasive ventilator time, non-invasive ventilator use the guide., Methods: Using prospective clinical observation research methods, Randomly divide 100 cases ranged from 6 months to 3 years old in cardiopulmonary bypass after congenital heart disease surgery patients into ultrasound group and control group, 50 cases in each group. All postoperative give positive cardiac function maintenance, diuresis, etc. Ultrasound group adopted the pulmonary ultrasound in children with pulmonary interstitial pulmonary edema monitoring and guide to extubation, enable the timing of the noninvasive ventilator support; Control group based on the bedside chest X-ray lung condition. Compare two groups of children with mechanical ventilation time (including the invasive and noninvasive ventilator support), noninvasive ventilator utilization rate and its accuracy, start the noninvasive ventilator time, the incidence of ventilator associated pneumonia (VAP), secondary tracheal intubation cases and ICU stay time, etc., Results: The ultrasound group compared with the control group in Invasive ventilator time [(15.0 ± 11.0) vs (20.0 ± 13.5, P=0.043)], noninvasive ventilation time [(38.5 ± 11.8) vs (48.6 ± 21.9, P=0.032)], the number of cases of the use of noninvasive ventilation (10 cases vs 22 cases, P=0.041), the correct use of the number of cases (10 vs 14, P=0.034) and VAP cases (3 vs 8, P=0.044), there was statistical significance, P< 0.05. The ultrasound group of children with ICU stay time was significantly lower than the control group [(66.0 ± 38.9) vs (82.0 ± 42.4, P=0.038)]; Control group had 2 cases with secondary tracheal intubation, ultrasound group one, comparing the two groups has no statistical significance (P> 0.05)., Conclusion: Postoperative children with congenital heart disease using pulmonary ultrasound evaluation of pulmonary interstitial edema,guide the ventilator, it can effectively shorten (invasive and noninvasive mechanical ventilation time and ICU length of hospital stay, lung ultrasound has instant, noninvasive, No radiation, repeatable,pulmonary ultrasound will be important after cardiopulmonary bypass interstitial lung edema diagnosis, evaluation of treatment means and helps to treat critically ill children.

Objective: To observe the effect of one lung ventilation (OLV) preconditioning on perioperative oxygenation during pediatric video-assisted thoracoscopic surgeries (VATS)., Methods: A total of 171 children aged 5 days to 11 years underwent VATS for empyema dissection and abscess excisions (n=55), mediastinal tumor resection (n=34), repair of the diaphragmatic hernia or diaphragmatic plication (n=21), pulmonary lobectomy or biopsy (n=43), or esophageal disease (n=18). Of these patients, 127 were younger than 3 years of age. A 5-Fr pediatric endobronchial blocker was used for OLV with a delivered inspired oxygen fraction (FiO(2)) of 1.0. After lateral decubitus, a sequential protocol of a 5- to 8-min OLV preconditioning and a 5-min two lung ventilation (TLV) was performed followed by OLV again before incision for VATS. In cases of a SpO(2)<95% without malposition of the blocker during OLV, a 5 cm H(2)O positive end expiratory pressure was applied; TLV was maintained for a SpO(2)<90%., Results: OLV provided good surgical conditions in 160 cases. Acceptable saturations were achieved in 166 cases during OLV. In 2 cases in empyema group and 3 in esophageal disease group, the ventilation protocol was converted to intermittent TLV during the operation due to hypoxemia. In esophageal disease group, the procedure and OLV duration, postoperative ventilation time and length of stay (LOS) were the longest among the groups, and the number of cases developing postoperative atelectasis was greater than that in diaphragmatic hernia and pulmonary disease groups. In empyema and esophageal disease groups, the oxygenation index (PaO(2)/FiO(2)) after total collapse of the lung in OLV and after extubation were lower than that in mediastinal tumor group (P<0.05 or 0.01)., Conclusion: A OLV preconditioning can maintain an acceptable oxygenation during pediatric OLV. A longer procedure and OLV duration is associated with a prolonged postoperative length of ventilation and LOS.

Objective: To explore the application of enteral immune nutrition preparation for chronic obstructive pulmonary disease (COPD) patients and examine the improving effects on nutritional status, immune status and acute inflammatory reaction., Methods: A total of 60 cases of hospitalized COPD patients on mechanical ventilation in intensive care unit (ICU) were randomly divided into immune nutrition group (containing essential fatty acids, omega-3 fatty acids, energy 1.3 kcal/ml) (study, n = 30) and standard nutrition group (self-made homogenized diet 1.2 kal/ml) (control, n = 30). Two groups received an equal calorie of enteral nutrition via a nasointestinal tube. On the day of admission and every 2 weeks, venous blood samples were drawn for measuring the serum levels of albumin (ALB), prealbumin (PA), C-reactive protein (CRP) and interleukin-6 (IL-6). And the values of upper arm muscle circumference (MAMC) were recorded simultaneously bedside. The levels of mechanical ventilation and weaning rate were compared between two groups at Day 14., Results: The weaning rate within 14 days in study group was higher than that in control group (73.3% vs 43.3%, P < 0.05). And PA at Day 14 in study group was higher than that in control group [(188.4 ± 57.5) vs (174.6 ± 65.7) mg/L, P < 0.05], ALB at Day 14 also higher than control group [(32.7 ± 4.6) vs (30.2 ± 3.8) g/L, P < 0.05], MAMC at Day 28 better than control group [(25.5 ± 2.1) cm vs (24.3 ± 1.8) cm, P < 0.05]. No significant inter-group difference in IL-6 existed at Day 14 [(250.1 ± 110.3) vs (266.1 ± 97.3) ng/L, P > 0.05]. The study group was lower than control group at Day 28 [(108.5 ± 59.6) vs (165.7 ± 76.3) ng/L, P < 0.05]. The CRP levels at Day 14 [(12.2 ± 7.3) vs (13.2 ± 6.9) mg/L, P < 0.05] and at Day 28 [(7.5 ± 5.0) vs (9.6 ± 5.6) mg/L, P < 0.05] were lower than those of control group at Days 14 and 28., Conclusion: Compared with homogenized diet, immune enteral nutrition may improve the nutritional status of COPD patients, lower the levels of acute inflammatory reactions and boost the success rate of early weaning.

Objective: To assess the reliability of the variability of the inferior vena cava diameter as an indicator of fluid responsiveness in critically ill patients with atrial fibrillation., Methods: Adult critically ill patients with atrial fibrillation requiring mechanical ventilation were enrolled. The variability of the inferior vena cava diameter (V(IVC)) was measured during a breath and then calculated as the maximum diameter (Dmax) minus minimum diameter (Dmin) divided by Dmin. All the hemodynamic parameters were collected at baseline and after a manoeuvre of passive leg raising (PLR). A 15% of VTI increase after the PLR was the criterion to identify the patients with or without fluid responsiveness. ROC curve was used to assess the sensitivity and specificity of V(IVC) as an indicator of fluid responsiveness for critically ill patients with atrial fibrillation., Results: There were 34 patients enrolled in our study, with 14 of them responsed to PLR and the rest 20 did not. For patients with fluid responsiveness V(IVC) was significantly higher than patients without fluid responsiveness. The sensitivity and specificity of V(IVC) ≥ 16% to predict fluid responsiveness in patients with atrial fibrillation were 57.1% and 89.9% respectively., Conclusion: V(IVC) proved to be a reliable predictor of fluid responsiveness in critical ill patients with atrial fibrillation.

Objective: To investigate the ideal persistence time of prone position ventilation in patients with severe acute respiratory distress syndrome (ARDS)., Methods: Collect 78 cases of severe ARDS admitted to the ICU unit of Sichuan Provincial People's Hospital from October 2012 to June 2014, all the ARDS patients needed to receive 8 h/day prone position continuous 5 day. For each of the prone position ventilation, ultrasound patterns were recorded and the aeration scores were calculated at the beginning of the prone position (T0) and 2 h (T1), 4 h (T2), 6 h (T3), 8 h (T4) later. The correlation of the aeration score variation (ASV) and the arterial blood gas indexes (pH, PaO(2), PaCO(2), PaO(2)/FiO(2)) were recorded also. The adverse reactions, ventilator situation and oxygen fraction after 7 days, 28-day mortality were monitored., Results: The aeration score of the lung at T1, T2, T3, T4 was significantly reduced than T0 all, the ventilation situation of mainly areas was improved after 2 h PPV (P < 0.05), 4 h later it was not distinguished (P > 0.05); the value of PaO(2), PaO(2)/FiO(2) was greater at T1, T2, T3, T4 than T0 (P < 0.05), the value of the oxygen fraction was significant increased at T2 than T1 (t = 2.840, P < 0.05); the number of patients with oxygen fractions > 300 mmHg after 5 days PPV was 65 (83.3%); there were 30 (38.5%) patients free of mechanical ventilation after 7 days; the 28-day mortality was 7 (8.97%)., Conclusion: In patients with severe ARDS, applicating 2-4 hours validity of prone position ventilation significantly improves the pulmonary ventilation, more than 4 h PPV do not better for patients probably.

Objective: To estimate the efficacies of fluid resuscitations as guided by lactate clearance rate (LC) and central venous oxygen saturation (ScvO₂) in patients with septic shock., Methods: 100 patients diagnosed with septic shock from June 2012 to June 2014 in department of critical care medicine of sixteen hospitals were enrolled. They were randomly divided into two groups of study and control (each n = 50). After a diagnosis of sepsis shock, they were treated symptomatically timely and fluid resuscitation was started as early as possible according to the 2008 Guideline for Managing Sepsis & Septic Shock. Central venous pressure (CVP) ≥ 8 mmHg (1 mmHg = 0.133 kPa), mean arterial pressure (MAP) ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹, ScvO₂≥ 70% and LC ≥ 10% (or lactate ≤ 2.0 mmol) served as target values for fluid resuscitation therapy in study group versus CVP ≥ 8 mmHg, MAP ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹ and ScvO₂≥ 70% in control group. The general conditions and clinical characteristics, changes in CVP, MAP, urine output, ScvO₂, lactate level and/or LC before (0 hour) and every hour (1-6 h) after the start of fluid resuscitation and other related outcome indicators were recorded., Results: No significant difference existed in general data. The 28-day mortality was 40% for study group versus 56% for control group. There was no significant inter-group difference (P > 0.05). The time of mechanical ventilation and length of intensive care unit (ICU) stay were lower in study group than those in control group [mechanical ventilation time (11.200 ± 17.069) vs (15.760 ± 14.215), P = 0.150; length of ICU stay (13.240 ± 17.127) vs (23.980 ± 18.298), P = 0.003]. The 28-day mortality was independently associated with LC and ScvO₂reaching target values for fluid resuscitation in study group (χ² = 10.930, P = 0.001) while the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation in control group (χ² = 6.395, P = 0.011). Among all patients, the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation (χ² = 14.530, P = 0.000), but not LC (χ² = 1.175, P = 0.278)., Conclusion: A combination of LC and ScvO₂may serve an index in confirming the endpoint of fluid resuscitation for patients with septic shock. Fluid resuscitation therapy under the guidance of LC and ScvO₂is more accurate and reliable than the guidance of ScvO₂alone.

Objective: To the evaluate chemo-responsiveness in patients with obesity hypoventilation syndrome (OHS) and respiratory failure (RF)., Methods: A total of 14 OHS and RF patients with a mean body mass index (BMI) of (34.3 ± 2.68) kg/m(2) hospitalized between January 2009 to December 2011 were recruited. Lung function test (LFT), polysomnograghy (PSG), arterial blood gases (ABG) before and after voluntary hyperventilation maneuver and respiratory responses to hypoxia (ΔVE/ΔSpO(2)) and hypercapnia (ΔVE/ΔPaCO(2)) were measured. Ten of them received bi-level positive airway pressure (BiPAP) for 1 week and pre and post-treatment ABG were compared., Results: All of them fulfilled the criteria of type II respiratory failure. PSG sleep study indicated a mean sleep apnea hypopnea index of (66.6 ± 30.1) times/h and LFT revealed a predicted FEV(1)/FVC% over 70%, excluding chronic obstruction pulmonary disease. Voluntary hyperventilation maneuver induced significant improvements in PaO(2) (52.5 ± 7.6 vs 81.3 ± 11.1 mmHg (1 mmHg = 0.133 kPa, P = 0.001) and PaCO(2) (50.4 ± 5.3 vs 43.2 ± 1.9 mmHg, P = 0.001). RF was reversed in all patients. As compared with normal controls, all patients had decreased ΔVE/ΔSpO(2) ((-0.11 ± 0.08) vs (-0.38 ± 0.04) L×min(-1)×%SpO(2)(-1), P < 0.001) and ΔVE/ΔPaCO(2) (0.31(0.18, 0.66) vs 1.20 (0.82, 1.50) L×min(-1)×mmHg(-1), P < 0.001). One-week BiPAP therapy induced significant improvement of sleep disordered breathing and daytime ABGs without any change of BMI in 10 patients. And PaCO(2) was normalized in 8/10 patients., Conclusions: OHS patients have sleep disordered breathing and depressed chemo-responsiveness. Voluntary hyperventilation maneuver may reverse the "unwilling breathing" type of RF. Non-invasive ventilation treatment may improve nocturnal sleep apnea and daytime ABG abnormality.

Objective: To evaluate the efficacy and safety of dexmedetomidine for post-operative elder patients on mechanical ventilation (MV)., Methods: For this randomized controlled trial, 108 cases of post-operative patients on MV were enrolled and assigned into either dexmedetomidine group (n = 54) or propofol group (n = 54) for sedation. And propofol was used for rescue. The dose of sedation was regulated by Ramsay score for maintaining a sedative score of 3-4. In both groups, fentanyl was provided intravenously continually for analgesia. The amount of fentanyl was adjusted according to the numerical rating scale (NRS) score for maintaining an analgesic score of 0-3. The average Ramsay score, the frequency of propofol, the highest score of NRS, the total dosage of fentanyl and recovery time were compared. Additional outcomes included duration of mechanical ventilation and intensive care unit (ICU) length. And the incidence of delirium and cardiovascular adverse events were compared for two groups., Results: No significant inter-group difference existed in the effectiveness of sedation. Compare with propofol group, the highest score of NRS decreased (1.8 ± 1.12 vs 3.1 ± 1.24, P < 0.05), the total dosage of fentanyl significantly decreased (427.6 ± 14.1 vs 658.4 ± 27.3 µg, P < 0.05) and recovery time became significantly shortened (0.3 ± 0.02 h vs 1.1 ± 0.3 h, P < 0.05) in dexmedetomidine group. Median duration of mechanical ventilation in dexmedetomidine group (21.0 h, 95%CI: 18.6-21.4 h) was significantly shorter than that in propofol group (28.0 h, 95%CI: 25.6-30.4 h) (P < 0.05). No inter-group differences existed in the ICU length of stay and the incidence of delirium. Two cases in dexmedetomidine group developed bradycardia while hypotension occurred in two cases of propofol group., Conclusion: Sedative effects of dexmedetomidine are safe and effective for post-operative elder patients on MV. And it offers a better efficacy of analgesia and shorter durations of MV and recovery time. But dexmedetomidine had no significant influence on the ICU length of stay or the incidence of delirium.

Objective: To explore the change of fluid balance in patients with septic shock for seven continuous days and examine its effect on clinical prognosis., Methods: A retrospective study was conducted for 105 patients with septic shock admitted into our intensive care unit (ICU) from May 2013 to February 2014. They were divided into non-survivors and survivors. Their baseline data, net balance quantity of fluid for seven continuous days and laboratory results were recorded and analyzed., Results: Among them, 28 patients died. Duration of mechanical ventilation, sequential organ failure assessment (SOFA) score and acute physiology and chronic health evaluation II (APACHE II) score were all lower in survivors than those in non-survivors (6 d vs 11 d, P = 0.002; 7 d vs 9 d, P < 0.001; 15 vs 19, P = 0.035). Yet hospitalization time in survivors was longer than that in non-survivors (30 d vs 18 d, P = 0.026) . According to trend graph on net balance of each day, the cumulative net negative fluid balance in survivors increased over time while it remained stable in non-survivors. Among seven days, the cumulative net fluid balance at Day 7 was most negatively correlated with survival days (r = -0.278, P = 0.006). Logistic regression analysis showed that SOFA score and cumulative net balance at Day 7 were the independent prognostic risk factors for septic shock. Moreover, at Day 7, no statistically significant inter-group difference existed in serum creatinine, alanine aminotransferase, PO(2)/FIO(2) and cardiac troponin I levels. But serum total bilirubin in survivors was lower than that in non-survivors (16.0 vs 27.9, P = 0.031)., Conclusion: Cumulative net negative balance quantity of fluid in survivors was much more than that in non-survivors. SOFA score and net balance quantity of fluid at Day 7 were the independent prognostic risk factors for septic shock. Cumulative net fluid balance at Day 7 was most negatively correlated with survival days. No significant inter-group difference existed in organ function at Day 7.

Objective: To investigate the distribution and drug-resistance of bacteria in the lower respiratory tract in patients with tuberculosis and severe pneumonia receiving invasive mechanical ventilation., Methods: The clinical data, lower respiratory tract infection pathogens and bacterial drug sensitivity were analyzed in 208 patients receiving invasive mechanical ventilation for tuberculosis and severe pneumonia., Results: A total of 355 pathogenic microbial strains were obtained from the patients, among which 281 (79.2%) strains were Gram-negative bacteria, 62 (17.5%) were fungi, and 12 (3.4%) were Gram-positive bacteria. Mixed infections were found in 68 cases (19.2%). The sensitivity rates of meropenem, imipenem and amikacin were over 60% for Gram-negative bacteria, and those of teicoplanin, vancomycin, and fusidic acid were 100% for Gram-positive bacteria., Conclusion: The main pathogenic bacteria are Gram-negative bacteria, fungi and Gram-positive bacteria in the lower respiratory tract of patients with tuberculosis and severe pneumonia receiving mechanical ventilation. Meropenem, imipenem and amikacin are effective antibiotics for lower respiratory tract infections, and multi-drug resistance is frequent in these patients, which urges appropriate use of the antibiotics.

Objective: To explore the related factors of difficult-to-wean patients in medical intensive care unit (MICU)., Methods: A retrospective analysis was performed for 112 patients placed on mechanical ventilation. There were 63 males and 49 females with a mean age of (58 ± 26) years. Their primary diseases included acute exacerbation of chronic obstructive pulmonary disease (AECOPD) (n = 27), pneumonia (n = 20), asthma (n = 12) and neuromuscular diseases (n = 8). Basic admission profiles, underlying diseases, accompanying diseases and pre-weaning changes in physiological indicators were recorded. They were divided into 2 groups: successfully-weaned group and different-to-wean group. Logistic regression analysis was used to analyze the risk factors correlated with the difficult withdrawal of mechanical ventilation., Results: There were 27 (24.1%) difficult-to-wean patients on mechanical ventilation in MICU. Some underlying diseases had statistical significance in both groups, including AECOPD (χ(2) = 6.238, P = 0.028), idiopathic pulmonary fibrosis (χ(2) = 5.232, P = 0.025) and neuromuscular disease (χ(2) = 14.635, P = 0.007). The ratios of difficult-to-wean patients were 9/27, 2/6 and 6/8 respectively. There was statistical significance of pre-admission and pre-weaning oxygenation index between two groups (t = 2.183, 2.162, P < 0.05). Zubrod score at pre-weaning was also significantly different between two groups (t = 9.037, P < 0.05). Logistic regression indicated that the patients with severe heart failure (OR = 5.781), psychological disorders (OR = 4.654), obstructive sleep apnea (OR = 4.012), AECOPD (OR = 3.617) and neuromuscular diseases (OR = 2.885) were more vulnerable to weaning difficulties., Conclusion: The major risk factors of difficult-to-wean patients in MICU include severe heart failure, psychological diseases, obstructive sleep apnea, neuromuscular disease and AECOPD. And oxygenation and self-care capability may also affect weaning significantly.

Objective: To report a case of critical illness polyneuropathy (CIP) with Parkinson disease and discuss the development, clinical features and early diagnosis of this condition., Methods: The clinical data of a patient with CIP and Parkinson's disease and the relevant literature were reviewed., Results: This case showed no typical disease course of sepsis, and the condition exacerbated rapidly. The patient presented initially with abnormal homeostasis, followed by rapid onset of respiratory muscle weakness to require mechanical ventilation, but no limb weaknesses were detected. Intravenous antibiotics and aggressive treatment of sepsis did not produce any positive responses to wean from mechanical ventilation. Examinations of creatine kinase and cerebrospinal fluid showed no abnormalities. Electromyography and nerve conduction studies demonstrated declined nerve conduction velocity and decreased sensory and motor muscle action potentials, suggesting the possibility of CIP., Conclusion: In patients with Parkinson disease, the occurrence of sepsis with prolonged mechanical ventilation and limb weakness indicates the necessity of neurophysiological examination, muscle biopsies and laboratory tests, which may help detect CIP in the early phase. Proper interventions of sepsis may reduce the likeliness of CIP. Elimination of the risk factors and aggressive management of sepsis can be effective measures for preventing CIP.

Objective: To investigate the potential causes of respiratory failure in patients with interstitial lung disease (ILD) and evaluate the application value of mechanical ventilation (MV) in its treatment., Methods: This study included the clinical data of 47 ILD patients (29 males and 18 females) complicating respiratory failure and admitted to respiratory care unit (RICU) for receiving MV at Beijing Chaoyang Hospital from January 1, 1998 to June 30, 2008. The median age was 67 years old. And a retrospective analysis was conducted for clinical characteristics, potential causes of respiratory failure, RICU treatment, prognosis and causes of death, etc., Results: The causes of respiratory failure were as follows: respiratory infections (n = 18, 38.3%), respiratory infection superimposed aggravated ILD (n = 15, 31.9%), pulmonary embolism (n = 8, 17.0%), ILD with acute exacerbation (n = 5, 10.6%) and heart failure (n = 1, 2.1%). And the mortality rates of RICU were 55.6% (10/18), 73.3% (11/15), 5/8, 4/5 and 1/1 respectively. Upon initial admission into RICU, 31 cases received noninvasive ventilation and 16 cases tracheal intubation. The mortality rates were 54.8% and 87.5% respectively. And there was statistically significant difference between the groups (chi(2) = 5.014, P = 0.025). In all patients, the RICU mortality rate was 66.0% (31/47) and the hospital mortality rate 70.2% (33/47)., Conclusions: Respiratory infection, pulmonary embolism and acute exacerbation of ILD are the main common causes of respiratory failure in ILD patients. Noninvasive ventilation therapy is clinically preferable to invasive ventilation for ILD patients with respiratory failure.

Objective: To investigate the effect of vaporized perfluorocarbon (PFC) inspiration on cell apoptosis of intestine mucosa., Methods: 18 piglets are randomly assigned to 3 groups, VMV group (n=8), undergoing intra-bronchial infusion of dioctyl sodium sulfosuccinate so as to cause acute lung injury (ALI), then routine mechanical ventilation (MV) for 8 h during which vaporized PFC inspiration was given for 2 h, and then killed to have the small intestine taken out, CMV group (n=8), undergoing routine MV for 8 h after the establishment of ALI model as MV control group, and sham operation group (n=2), undergoing only laparotomy to take out the small intestine. Apoptosis index of intestine mucosa was examined by TUNEL. Immunohistochemistry was used to detect the protein expression of BAX and bcl-2. RT-PCR was used to detect the mRNA expression of BAX and bcl-2., Results: The apoptotic cells were mainly distributed in the intestinal villi of the VMV and CMV groups, and only a few apoptotic cells could be seen in the sham operation group. The apoptosis rate of the VMV group was (22.9+/-2.3)%, significantly lower than that of the CMV group [(70.6+/-3.4)%, P<0.05]. The protein expression of BAX of the VMV group was significantly lower than that of the CMV group (P<0.05), and the protein expressing of bcl-2 of the VMV group was significantly higher than that of the CMV group (P<0.05). The mRNA expression of BAX of the VMV group was 7.10+/-0.32, significantly lower than that of the CMV group (9.29+/-1.06, P<0.05), and the MRNA expression of bcl-2 of the VMV group was 10.29+/-2.51, significantly higher than that of the CMV group (5.18+/-1.08, P<0.05). The mRNA expression and protein expression of BAX and bcl-2 were all at very low levels in the sham operating group., Conclusion: PFC vaporized inspiration may reduce mucosa apoptosis of small intestine, with the possible mechanism of inhibiting the expression of the BAX gene and raising the expression of the bcl-2 gene.

Objective: To explore the significance of negative expiratory pressure (NEP) technique in detecting expiratory flow limitation (EFL) in the chronic obstructive pulmonary disease (COPD) patients., Methods: NEP technique was performed on 54 COPD patients, 45 males and 9 females, aged 69+/-10 (Group A), 8 COPD patients who failed to receive the routine pulmonary function tests (Group B), and 10 normal controls. The subjects in 3 groups, matched in age, height, body weight, and educational level, underwent 5-point EFL scoring, Medical Research Council (MRC) dyspnea scoring, 6-min walk distance scoring, and routine pulmonary ventilation function test., Results: EFL was detected in 41 of the 54 COPD patients in Group A. NEP test was successfully performed on the 8 patients of Group B, and 7 of them were found as with EFL. The level of forced expired volume in one second percentage (FEV1%) of the patients with the EFL scores of 2, 3, and 4 were 55.71%+/-11.77%, 41.21%+/-13.69%, and 29.84%+/-11.65% respectively, all significantly lower that of the 0-score group (83.76%+/-16.44%, all P<0.05). Multiple stepwise regression analysis showed that only 5-point EFL score, FEV1%, and 6-min walking distance were associated with MRC dyspnea score, and the 5-point EFL score showed the best associativity with dyspnea., Conclusion: As compared with FEV(1pred)%, 5-point EFL scoring is more reliable in evaluating the dyspnea of COPD patients, it is simple and doesn't't require any cooperation on the part of the patients. NEP technique can be applied in the COPD patients who fail to receive the routine pulmonary function tests.

Objective: To observe the influence of mechanical ventilation (MV) on rat's lung and the expression changes of lung endotoxin receptor CD14 mRNA., Methods: Forty-eight male SD rats weighing 330-360 g were randomly divided into 4 groups (n = 12 each): group R received no mechanical ventilation, group P received small MV (VT = 6 ml/kg, PEEP = 8 mm Hg), group M received conventional MV (VT = 12 ml/kg, PEEP = 0 mm Hg), and group N received large tidal volume mechanical ventilation (VT = 40 ml/kg, PEEP = 0 mm Hg). The animals were anesthetized with intraperitoneal pentobarbital 100 mg x kg(-1), tracheotomized and mechanically ventilated (I:E = 1:1, FiO2 = 21%). The respiratory rate (RR) of MV was adjusted to maintain the end-tidal carbon dioxide in the rang of 35-45 mm Hg throughout the procedure. Right carotid artery and left femoral vein were cannulated for BP monitoring and fluid and drug administration. 6 rats in each group were injected 50 mg/kg Evans Blue (EB). The experiment was culminated in 3 hours, then the rats were killed by exsanguination via arteria carotis interna. Morphologic change scores of the rats' lungs, wet/dry weight ratio of lung tissue (W/D), bronchial lavage fluid (BALF) inflammatory cell population, and permeability of vessel wall were evaluated. The concentration of TNF-alpha and MIP-2 in the plasma were determined by enzyme immunoassay method (ELISA). The expressions of lung tissue endotoxin receptor CD14 were detected by RT-PCR, macrophage CD14 in BALF was also detected by immunohistochemistry., Results: pulmonary pathomorphology scores: there were no alteration in R group and P group, but it were slightly increased in M group, there was significantly elevated in N group as compare to M group (F = 8.0, P = 0.000). Pulmonary tissue wet/dry weight ratio (W/D): Compare with R group, There was no statistically significant difference in P group and M group; the elevation in N group (t = 4.103, P = 0.02), EB: Compare with R group, There was no statistically significant difference in P group and M group; the obviously elevation in N group (t = 36.634, P = 0.000). WBC in BALF: Compare with R group, there was no change in P group, the elevation in M group (t = 4.272, P = 0.02), there was significantly elevated in N group (F = 26.68, P = 0.000). TNF-alpha had no manifest variation in 4 groups. MIP-2: compare with R group (31.5 +/- 2.4), There was no statistically significant difference in P group (35.4 +/- 5.3), the elevation in M group (44.7 +/- 6.9, t = 7.85, P = 0.04), there was significantly elevated in N group (167.7 +/- 11.8, t = 27.779, P = 0.000). The expressions of macrophage CD14 protein in BALF and lung tissue CD14 mRNA were fundamentally coincident in R group and P group; the expressions of CD14 mRNA were elevated, but the expressions of CD14 protein were no change in M group; the expressions of CD14 in N group manifestly elevated (P = 0.000)., Conclusions: Conventional MV induces minor injury in rat's lung and can up regulate the expression of CD14 mRNA in the lung, but not up regulate the expression of CD14 protein; large tidal volume MV induces injury of rat's lung and evidently up regulates CD14 expression in the lung. Protective MV can avoid the above mentioned variations in rat's lung.

Objective: To investigate the efficacy of high frequency oscillation with perfluorocarbon (PFC) in rabbits with acute lung injury (ALI)., Methods: Twenty four rabbits with ALI induced by repeated saline lung lavage were randomly assigned to four groups: conventional mechanical ventilation (CMV) group, CMV + PFC group, high frequency oscillation (HFO) group and HFO + PFC group. All rabbits were ventilated for two hours. Blood gases, respiratory system dynamic compliance (Cdyn) and intrapulmonary shunt fraction (Qs/Qt) were measured and calculated at 30, 60, and 120 min during experiment., Results: Compared with the CMV, statistically improvements were shown in gas exchange, Cdyn and Qs/Qt at 30 min in the CMV + PFC group [PaO(2) 122 mm Hg +/- 15 mm Hg vs. 692 mm Hg +/- 82 mm Hg, PaCO(2) 29.1 mm Hg +/- 2.7 mm Hg vs. 47.1 mm Hg +/- 2.9 mm Hg, Cdyn (1.35 +/- 0.13) vs (0.97 +/- 0.13) ml.cm H(2)O(-1).kg(-1), Qs/Qt 18.1 +/- 1.1 vs.24.5 +/- 2.9] (P < 0.01 approximately 0.05) and remained stable for two hours. Compared with HFO, HFO + PFC improved oxygenation and ventilation more rapidly than HFO did. At 30 min intervals gas exchange and Qs/Qt were significantly improved (PaO(2) 174.9 +/- 18.5 vs 132.3 +/- 19.4, PaCO(2) 26.1 +/- 2.6 vs 34.9 +/- 4.6, Qs/Qt 17.1 +/- 2.4 vs 19.8 +/- 0.9) (P < 0.05)and remained stable to 60 min. The same differences were seen at 60 min., Conclusion: In rabbits with ALI, CMV + PFC could induce a significant improvement in gas exchange and Cdyn. HFO + PFC leads more rapidmy to reach best gas exchange and Cdyn.