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To define a set of indicators that could be used to improve quality in intensive care medicine.An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes.A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes.This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

Background Scientific evidence is accumulating that non-invasive ventilation (NIV) may be beneficial for different patient groups with acute respiratory insufficiency (ARI). The aim of the new S3 guidelines is to propagate evidence-based knowledge about the indications and limitations of NIV in clinical practice. Methods A total of 28 experts from 12 German medical societies were involved in the process of development of the present guidelines. These experts systematically analyzed approximately 2,900 publications. Finally, the recommendations were discussed and approved in two consensus conferences. Results In hypercapnic ARI, NIV reduces the length of stay and mortality during intensive care treatment [grade A recommendation (A)]. Patients with cardiopulmonary edema should be treated with continuous positive airway pressure (CPAP) or NIV (A). For immunocompromized patients with ARI, NIV reduces the mortality (A). In patients with postextubation respiratory failure and during weaning from mechanical ventilation, NIV reduces the risk of reintubation (A). For patients who decline to be ventilated invasively, NIV may be an acceptable alternative (B). Non-invasive ventilation can also successfully be used in pediatric patients with ARI caused by different reasons (C). In acute respiratory distress syndrome (ARDS) NIV cannot generally be recommended because the failure rate is relatively high. Conclusion Non-invasive ventilation is still not as widely implemented in clinical medicine as would be expected on the basis of the scientific literature. The aim of the present guidelines is to further propagate NIV for the treatment of ARI.

Mechanical ventilation is a lifesaving procedure in routine intensive care medicine. However, during recent years we have learned that intubation and prolonged mechanical ventilation can be associated with quite serious side effects. Therefore, one of the major goals in the management of the mechanically ventilated patient is to liberate the patient from the ventilator at the earliest time possible. In about 20% of all mechanically ventilated patients, the process of weaning is difficult and time consuming so that these patients need a specific weaning technique. It has been shown that the duration of weaning might be shortened and its outcome might be improved when standardized protocols are used to detect the earliest time when a patient is able to breath spontaneously. However, although this evidence suggests that it is in general possible to improve the process of weaning, those studies have not resulted in a clear preference for one or the other weaning method. Both, T-piece trials as well as spontaneous breathing trials with low level pressure support have been successfully used for weaning. Since it is well known that the intubated patients has to overcome an additional breathing workload which is imposed mainly by the endotracheal tube, we have a preference for the spontaneous breathing trials using pressure support to compensate for this added workload.

Objective: To evaluate the effect of inhaled nitric oxide (NO) on gas exchange and haemodynamics during partial liquid ventilation, in a saline lung lavage model of acute lung injury (ALI) in pigs. Design: Prospective, controlled study. Setting: Animal research facilities of a university hospital. Subjects: Twelve medium-sized pigs. Interventions: After induction of ALI in 12 pigs (25±5 kg body weight), partial liquid ventilation was initiated with 30 ml kg-1 perfluorocarbon (FC 3280 ®). Subsequently, 0.1 ppm, 1 ppm, 10 ppm and 100 ppm NO were sequentially added to the inspiratory gas, interrupted by time periods without NO inhalation. Measurements and main results: PaO2, PaCO2 and venous admixture did not reveal any significant change following partial liquid ventilation or the additional inhalation of NO. However, a large variety of individual responses were observed in the studied group of animals. Mean pulmonary pressure increased significantly after inhalation of 10 ppm NO and 100 ppm NO was interrup...

Background: Two prototypes for integrated nitric oxide (NO) administration during mechanical ventilation have recently been developed (Servo 300 NO-A prototype, Siemens, Lund, Sweden; NO-domo, Drager AG, Lubeck, Germany). Objectives: To test the accuracy for the administration and the inbuilt electrochemical NO/NO2 measurement of these prototypes. Design: Different NO concentrations (NOin, 0.5-90 ppm) and different tidal volumes (TV, 100-250 ml for paediatric patients, 300-1,000 ml for adult patients) were tested. Both the adjusted NOin as well as the electrochemical measurement were compared to chemiluminescence as the reference method. Results: The mean difference between NOin and chemiluminescence measurements was 0.46±0.72 ppm for the Servo and 0.61±2.01 ppm for the NO-domo. This difference was dependent on TV and NOin. For NOin ≤40 ppm and the adult range of TV, the mean difference was 0.17±0.25 ppm for the Servo and 1.00±0.48 ppm for the NO-domo. The comparison between the electrochemical measureme...

The airway occlusion pressure, P0.1, is an index for the neuro-muscular activation of the respiratory system. It has been shown to be a very useful indicator for the ability of patients receiving ventilatory support to be weaned from mechanical ventilation. Since the standard measurement technique for P0.1 determination is technically complex, it is not widely available for clinical purposes. For that reason a P0.1 measurement technique was developed as an integrated function in a standard respirator (Evita, Drager, Lubeck, Germany). This technique is easy to use and does not need any further equipment. We validated this new technique by comparing it to standard P0.1 measurements in a mechanical lung model as well as in ventilated patients. In the lung model we found a correlation between the Evita measurement and standard measurements of r = 0.99. In 6 ventilated patients the correlation was r = 0.78. Since the Evita P0.1 and the standard measurement had to be performed during two different breaths, this little poorer correlation in patients may be due to a significant breath-by-breath variability in P0.1. Comparing the Evita P0.1 and the standard measurement within one breath resulted in a clearly better correlation (r = 0.89). We conclude that this new measurement technique provides an easy and accurate P0.1 measurement using standard respiratory equipment when tested in a lung model. In patient measurements the method is less precise, which is probably due to the variable waveforms of the inspiratory driving pressure seen in patients, for example when intrinsic PEEP is present.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective multicenter study was carried out from October 1 to November 30, 1991, to determine the incidence, severity, and mortality of acute respiratory failure (ARF) in Berlin, Germany, a metropolis with a population of 3.44 million. Adult patients from 72 intensive care units (ICUs) were evaluated. ARF was defined as: (1) intubation and mechanical ventilation (I+MV) > or = 24 h; age > or = 14 yr. Incidence of ARF was assessed as the number of patients fulfilling ARF criteria within the 2-mo study period. Severity of ARF was defined as "no lung injury" (NLI), "mild-to-moderate lung injury" (MMLI), and "severe lung injury" (SLI) according to Murray and coworkers' proposals. Mortality was assessed as number of patients with ARF dying during ICU stay. During the study period, 508 patients were diagnosed as having ARF, representing an incidence of ARF of 88.6 per 100,000/yr. Twenty-four h after I+MV, MMLI occurred in 94% and SLI in 3.6% of the ARF patients. Overall mortality rate was 42.7%. Mortality rate in the NLI group was 36.4%; in patients with MMLI, 40.8%; and in patients with SLI, 58.8%. Our data offer novel information on incidence, severity, and mortality of ARF in a major urban population.

Objective: We designed a new ventilatory mode to support spontaneously breathing, intubated patients and to improve weaning from mechanical ventilation. This mode, named Automatic Tube Compensation (ATC), compensates for the flow-dependent pressure drop across the endotracheal tube (ETT) and controls tracheal pressure to a constant value. In this study, we compared ATC with conventional patient-triggered inspiratory pressure support (IPS). Design: A prospective, interventional study. Setting: A medical intensive care unit (ICU) and an ICU for heart and thoracic surgery in a university hospital. Patients: We investigated two groups of intubated, spontaneously breathing patients: ten postoperative patients without lung injury, who had a normal minute ventilation (VE) of 7.6 ± 1.7 l/min, and six critically ill patients who showed increased ventilatory demand (VE = 16.8 ± 3.0 l/min). Interventions: We measured the breathing pattern [VE, tidal volume (VT), and respiratory rate (RR)] and additional work of breathing (WOBadd) due to ETT resistance and demand valve resistance. Measurements were performed under IPS of 5, 10, and 15 mbar and under ATC. Results: The response of VT, RR, and WOBadd to different ventilatory modes was different in both patient groups, whereas VE remained unchanged. In postoperative patients, ATC, IPS of 10 mbar, and IPS of 15 mbar were sufficient to compensate for WOBadd. In contrast, WOBadd under IPS was greatly increased in patients with increased ventilatory demand, and only ATC was able to compensate for WOBadd. Conclusions: The breathing pattern response to IPS and ATC is different in patients with differing ventilatory demand. ATC, in contrast to IPS, is a suitable mode to compensate for WOBadd in patients with increased ventilatory demand. When WOBadd was avoided using ATC, the patients did not need additional pressure support.

The pathophysiology of ALI and ARDS induces distinct changes in respiratory mechanics. For more than 30 years respiratory mechanics have been assessed by analysis of the static pressure–volume (P–V) curve. Ventilation, however, is a dynamic process and the mechanical properties of the respiratory system can be assessed under dynamic conditions [1]. If the respiratory system shows a specific dynamic behaviour that is not present during static conditions, differing results are to be expected if mechanics are analysed during dynamic conditions. The aim of the present study was to test whether such differences can be observed in ARDS and ALI.