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BACKGROUND: Cancer patients may require intensive care support for postoperative care, complications associated with underlying malignancy, or toxicities related to cancer therapy. The higher mortality rates found in this population than in the population of ICU patients without cancer may be attributable to confounding due to a higher prevalence of multiple organic dysfunctions at ICU admission in patients with malignancy; however, data regarding this hypothesis are scarce. Accordingly, we performed the present study to compare the crude and propensity score-matched mortality rates between adult subjects with and without cancer admitted to a mixed medicalsurgical ICU. METHODS: We conducted a retrospective analysis of a comprehensive longitudinal ICU database in a tertiary referral hospital in Southern Brazil. All adult subjects who were admitted to the ICU from January 2008 to December 2014 were evaluated. Crude and propensity score-matched all-cause 30-d mortality rates of critically ill subjects with cancer were compared with those of critically ill subjects without cancer. RESULTS: A total of 4,221 subjects were evaluated. The survival analysis revealed that the crude mortality rate was higher among subjects with cancer than among subjects without cancer (18.7% vs 10.2%, P < .001). However, after matching by propensity score, the 30-d mortality rates of subjects with and without cancer were similar (18.5% vs 15.2%, P = .17). CONCLUSIONS: The present study failed to show an association between malignancy and all-cause 30-d mortality rate in adult subjects admitted to a mixed medical-surgical ICU. The propensity score-matched analysis showed no evidence of excessive mortality due to cancer diagnosis. [ABSTRACT FROM AUTHOR]

Spontaneous breathing trials (SBTs) are among the most commonly employed techniques to facilitate weaning from mechanical ventilation. The preferred SBT technique, however, is still unclear. To clarify the preferable SBT (T-piece or pressure support ventilation [PSV]), we conducted this systematic review. We then searched the MEDLINE, EMBASE, SciELO, Google Scholar, CINAHL, ClinicalTrials.gov, and Cochrane CENTRAL databases through June 2015, without language restrictions. We included randomized controlled trials involving adult subjects being weaned from mechanical ventilation comparing T-piece with PSV and reporting (1) weaning failure, (2) re-intubation rate, (3) ICU mortality, or (4) weaning duration. Anticipating clinical heterogeneity among the included studies, we compared prespecified subgroups: (1) simple, difficult, or prolonged weaning and (2) subjects with COPD. We summarized the quality of evidence for intervention effects using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. We identified 3,674 potentially relevant studies and reviewed 23 papers in full. Twelve studies (2,161 subjects) met our inclusion criteria. Overall, the evidence was of very low to low quality. SBT technique did not influence weaning success (risk ratio 1.23 [0.94-1.61]), ICU mortality (risk ratio 1.11 [0.80-1.54]), or re-intubation rate (risk ratio 1.21 [0.90-1.63]). Prespecified subgroup analysis suggested that PSV might be superior to T-piece with regard to weaning success for simple-to-wean subjects (risk ratio 1.44 [1.11-1.86]). For the prolonged-weaning subgroup, however, T-piece was associated with a shorter weaning duration (weighted mean difference -3.08 [-5.24 to -0.92] d). In conclusion, low-quality evidence is available concerning this topic. PSV may be associated with lower weaning failure rates in the simple-to-wean subgroup. In contrast, in prolonged-weaning subjects, T-piece may be related to a shorter weaning duration, although this is at high risk of bias. Further study of the difficult-to-wean and COPD subgroups is required. [ABSTRACT FROM AUTHOR]

BACKGROUND: Both premature and delayed liberation from mechanical ventilation are associated with increased morbidity and mortality, and fluid balance could negatively influence extubation outcomes. We sought to determine the impact of fluid balance in the 48 h before a spontaneous breathing trial (SBT) on weaning outcomes in a mixed ICU population. METHODS: This was a prospective observational study in 2 adult medical-surgical ICUs. All enrolled subjects met eligibility criteria for weaning from mechanical ventilation. SBT failure was defined as inability to tolerate a T-piece trial for 30-120 min. Data on demographics, physiology, fluid balance in the 48 h preceding SBT (fluid input minus output over the 48-h period), lung ultrasound findings, and outcomes were collected. RESULTS: Of a total of 250 SBTs, SBT failure eventuated in 51 (20.4%). Twenty-nine subjects (11.6%) had COPD, and 40 subjects (16%) were intubated due to respiratory sepsis. One-hundred eighty-nine subjects (75.6%) were extubated on the first attempt. Compared with subjects with SBT success, SBT failure subjects were younger (median of 66 vs 75 y, P = .001) and had a higher duration of mechanical ventilation (median of 7 vs 4 d, P < .001) and a higher prevalence of COPD (19.6 vs 9.5%, P = .04). There were no statistically significant differences in 48-h fluid balance before SBT between groups (SBT failure, 1,201.65 ± 2,801.68 mL; SBT success, 1,324.39 ± 2,915.95 mL). However, in the COPD subgroup, we found a significant association between positive fluid balance in the 48 h before SBT and SBT failure (odds ratio of 1.77 [1.24-2.53], P = .04). CONCLUSIONS: Fluid balance should not delay SBT indication because it does not predict greater probability of SBT failure in the medical-surgical critically ill population. Notwithstanding, avoiding positive fluid balance in patients with COPD might improve weaning outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: There have been few reports of factors affecting aerosol delivery during noninvasive ventilation (NIV). Nebulization is a standard practice, and our objective was to determine the effect of spontaneous breathing (SB) and NIV mode on lung technetium-99m (99mTc) deposition in subjects with normal lungs. METHODS: Thirteen health care volunteers were submitted to a randomized radioaerosol nebulization with 99mTc during SB, CPAP (10 cm H2O), and bi-level positive-pressure ventilation (bi-level; inspiratory-expiratory pressures of 15/5 cm H2O). NIV was performed via a ventilator (VPAP II ST-A, ResMed, Sydney, Australia). The radioaerosol deposition was evaluated by pulmonary scintigraphy after 10 min of inhalation. Regions of interest (ROIs) were outlined on the left lung (LL), right lung (RL), and trachea (TRQ). The average number of counts/pixel in each ROI was determined, and the ratio of lung and trachea was calculated. RESULTS: The three techniques showed comparable lung deposition. Analysis of radioaerosol deposition in the lungs showed a mean count at RL of 108.7 ± 40 with CPAP, 111.5 ± 15 with bi-level, and 196.6 ± 167 with SB. At LL, the values were 92.7 ± 15 with CPAP, 98.4 ± 14 with bi-level, and 225.0 ± 293 with SB. There was no difference between the means of radioaerosol deposition in RL, LL, or TRQ, as well as the lung calculated ratio (LCR = [RL + LL]/TRQ), which was similar in comparing ventilatory strategies. CONCLUSIONS: Based on our data, there is an equivalent deposition of inhaled substances in individuals with healthy lungs when SB, CPAP, and bi-level are compared. [ABSTRACT FROM AUTHOR]

BACKGROUND: The administration of a high FIO2 to COPD patients breathing spontaneously may result in hypercapnia, due to reversal of preexisting regional hypoxic pulmonary vasoconstriction, resulting in a greater dead space. Arterial blood gas trends have not been reported in these patients. In a 31-bed medical ICU in a teaching hospital we prospectively investigated the response of 17 CO2 -retaining COPD patients, after acute respiratory crisis stabilization with noninvasive ventilation, to an FIO2 of 1.0 for 40 min, after having been noninvasively ventilated with an FIO2 of ≤ 0.50 for 40 min. RESULTS: The mean ± SD baseline findings were: PaO2 101.4 ± 21.7 mm Hg, PaCO2 52.6 ± 10.4 mm Hg, breathing frequency 17.8 ± 3.7 breaths/min, tidal volume 601 ± 8 mL, and Glasgow coma score of 14.8 ± 0.3. PaO2 significantly increased (P < .001) when FIO2 was increased to 1.0, but there was no significant change in PaCO2, breathing frequency, tidal volume, or Glasgow coma score. CONCLUSIONS: During noninvasive ventilation with an FIO2 sufficient to maintain a normal PaO2, a further increase in FIO2 did not increase PaCO2 in our CO2 -retaining COPD patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Critical illness myopathy and/or neuropathy (CRIMYNE) is a common alteration seen in the ICU. The currently available bedside methods of measuring respiratory and peripheral muscle function in critically ill patients are somewhat inadequate. The objective of this study was to evaluate the presence of diaphragmatic and peripheral CRIMYNE in septic patients with prolonged weaning from mechanical ventilation (MV). METHODS: Cohort prospective study with an entry period of 6 months. In 2 Brazilian medical-surgical ICUs, septic patients > 18 years of age, dependent on MV > 14 days, requiring prolonged weaning from MV, awake (Richmond Agitation Sedation Scale > -2), and with no previous history of polyneuropathy or myopathy were included. Electrophysiological studies of the limbs and also of the respiratory system by phrenic nerve conduction and needle electromyography of the diaphragm were performed in all subjects. RESULTS: Twelve subjects were enrolled during 6 months of study. The electrophysiological signs of peripheral CRIMYNE occurred in 9 subjects, 7 of whom died in the ICU. Three subjects developed critical illness polyneuropathy, 4 critical illness myopathy, and 2 both. Only one subject who developed peripheral CRIMYNE did not present diaphragmatic involvement, whereas no subject developed diaphragm involvement alone. Thus, electrophysiological signs of diaphragmatic CRIMYNE occurred in 8 of the 9 subjects with peripheral CRIMYNE. Upon clinical examination, 8 subjects were not able to moves their limbs against gravity, and these findings were related to the presence of peripheral and diaphragmatic dysfunction. CONCLUSIONS: Our pilot findings suggested that CRIMYNE is common in septic patients with prolonged weaning from MV(MV>14 d). The inability to move limbs against gravity is frequently associated with peripheral and diaphragmatic CRIMYNE, and the findings of CRIMYNE in peripheral electrophysiological tests are associated with diaphragmatic involvement. [ABSTRACT FROM AUTHOR]

Copyright of Brazilian Journal of Pulmonology / Jornal Brasileiro de Pneumologia is the property of Sociedade Brasileira de Pneumologia e Tisiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Brazilian Journal of Pulmonology / Jornal Brasileiro de Pneumologia is the property of Sociedade Brasileira de Pneumologia e Tisiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Questions: What is the effect of increasing pressure support during the application of manual chest wall compression with vibrations for secretion clearance in intubated patients in intensive care? Design: A randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. Participants: 66 patients receiving mechanical ventilation for greater than 48 hours. Intervention: All participants were positioned supine in bed with the backrest elevated 30 degrees. The experimental group received manual chest wall compression with vibrations during which their pressure support ventilation was increased by 10 cmH2O over its existing level. The control group received manual chest wall compression with vibrations but no adjustment of the ventilator settings. Both groups then received airway suction. Outcome measures: The primary outcome was the weight of the aspirate. Secondary outcomes were pulmonary and haemodynamic measures and oxygenation. Results: Although both treatments increased the weight of the aspirate compared to baseline, the addition of increased pressure support during manual chest wall compression with vibrations did not significantly increase the clearance of secretions, mean betweengroup difference in weight of the aspirate 0.4g, 95% CI -0.5 to 1.4. Although several other measures also improved in one or both groups with treatment, there were no significant differences between the groups for any of the secondary outcomes. Conclusion: Although increasing pressure support has previously been shown to increase secretion clearance in intubated patients, the current study did not show any benefits when it was added to chest wall compression with vibrations. [ABSTRACT FROM AUTHOR]

Abstract: Background: Predictor indexes are often included in weaning protocols and may help the intensive care unit (ICU) staff to reach expected weaning outcome in patients on mechanical ventilation. Objective: The objective of this study is to evaluate the potential of weaning predictors during extubation. Design: This is a prospective clinical study. Settings: The study was conducted in 3 medical-surgical ICUs. Patients: Five hundred consecutive unselected patients ventilated for more than 48 hours were included. Methods and Measurements: All patients were extubated after 30 minutes of successful spontaneous breathing trial and followed up for 48 hours. The protocol evaluated hemodynamics, ventilation parameters, arterial blood gases, and the weaning indexes frequency to tidal volume ratio; compliance, respiratory rate, oxygenation, and pressure; maximal inspiratory pressure; maximal expiratory pressure; Pao 2/fraction of inspired oxygen; respiratory frequency; and tidal volume during mechanical ventilation and in the 1st and 30th minute of spontaneous breathing trial. Results: Reintubation rate was 22.8%, and intensive care mortality was higher in the reintubation group (10% vs 31%; P < .0001). The areas under the receiver operating characteristic curve showed that tests did not discriminate which patients could tolerate extubation. Conclusion: Usual weaning indexes are poor predictors for extubation outcome in the overall ICU population. [Copyright &y& Elsevier]