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Purpose: This study aimed to evaluate an objective measure of cough strength, the peak cough expiratory flow (PCEF), as a predictive criterion of success or failure of extubation., Methods: Patients under mechanical ventilation for more than 24 h who successfully passed the spontaneous breathing trial were included in the study. Just before extubation, PCEF was measured with an electronic flowmeter., Results: A total of 130 patients were included. The median duration of mechanical ventilation before extubation was 8 days (4-17). Fourteen patients (10.8%) failed extubation. The sole factor significantly associated with extubation failure was the measure of PCEF. The patients who did not cough at order had a higher rate of extubation failure than those who did (P = 0.03). The mean PCEF of patients who failed extubation (36.3 +/- 15 l/min) was significantly lower than the one of patients who succeeded (63.6 +/- 32 l/min) (P < 0.001). The optimal cut-off value of PCEF was 35 l/min. Overall, an inability to cough at order or a PCEF < or =35 l/min predicted extubation failure with a sensitivity of 79% and a specificity of 71%. The risk of extubation failure was 24% for the patients who did not cough at order or with a PCEF < or =35 l/min and 3.5% for those with a PCEF >35 l/min [RR = 6.9 (95% CI, 2-24); P = 0.002]., Conclusions: This study confirmed the interest of measuring the PCEF to predict extubation outcome in patients having successfully passed the spontaneous breathing trial.

Objective: Comatose patients frequently exhibit pulmonary function worsening, especially in cases of pulmonary infection. It appears to have a deleterious effect on neurologic outcome. We therefore conducted a randomized trial to determine whether daily prone positioning would prevent lung worsening in these patients., Design: Prospective, randomized, controlled study., Setting: Sixteen-bed intensive care unit., Patients: Fifty-one patients who required invasive mechanical ventilation because of coma with Glascow coma scores of 9 or less., Interventions: In the prone position (PP) group: prone positioning for 4 h once daily until the patients could get up to sit in an armchair; in the supine position (SP) group: supine positioning., Measurements and Results: The primary end point was the incidence of lung worsening defined by an increase in the Lung Injury Score of at least 1 point since the time of randomization. The secondary end point was the incidence of ventilator-associated pneumonia (VAP). A total of 25 patients were randomly assigned to the PP group and 26 patients to the SP group. The characteristics of the patients from the two groups were similar at randomization. The incidence of lung worsening was lower in the PP group (12%) than in the SP group (50%) ( p=0.003). The incidence of VAP was 20% in the PP group and 38.4% in the SP group ( p=0.14). There was no serious complication attributable to prone positioning, however, there was a significant increase of intracranial pressure in the PP., Conclusion: In a selected population of comatose ventilated patients, daily prone positioning reduced the incidence of lung worsening.

Objective: To observe the nosocomial infection (NI) distribution in ventilated patients of a single intensive care unit (ICU) according to the kind of control of the upper airways: noninvasive positive pressure ventilation (NPPV) versus endotracheal intubation (ETI)., Setting: ICU of a general hospital., Design: Prospective clinical and epidemiologic survey., Patients: In the period December 1994-March 1997, 761 patients were included who needed mechanical ventilation for more than 48 h: 129 were ventilated by NPPV (NPPV group), 607 were intubated (ETI group) and 25 required intubation after a period of NPPV (NPPV-ETI group)., Measurements and Results: The data used were prospectively collected according to the NI epidemiologic surveillance protocol of "C. CLIN Sud Est, Réa Sud Est", France. NI included a ventilator-associated pneumonia (VAP), catheter-related infection, urinary tract infection and bacteremia. Occurrence of NI was estimated by the density of incidence. Covariate-adjusted NI and VAP risk factors were assessed by the Cox model. The incidence density of total NI was lower for NPPV than for ETI (14.2 versus 30.3 per 1000 patient-days, p < 0.01). The Cox model showed that the use of noninvasive ventilation, adjusted to the severity of illness (SAPS II), reduced not only the VAP risk (hazard ratio (HR) = 4.07) but also the NI risk (HR = 1.95)., Conclusion: The use of NPPV reduces the risk of VAP and NI, compared to ETI, irrespective of the severity of the patient's illness.