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Objective High tidal volume ventilation is associated with ventilator-induced lung injury. Early introduction of lung protective ventilation improves patient outcomes. This study describes ventilator management during critical care transport and the association between transport ventilator settings and ventilator settings in the intensive care unit (ICU). Methods This was a retrospective review of mechanically ventilated adult patients transported to an academic medical center via a critical care transport program between January 2018 and April 2019. Ventilator settings during transport were compared with the initial and 6- and 12-hour postadmission ventilator settings. Results Three hundred eighty patients were identified; 114 (30%) received tidal volumes > 8 mL/kg predicted body weight at the time of transfer. The transport handoff tidal volume strongly correlated with the ICU tidal volume (Pearson r = 0.7). Patients receiving high tidal volumes during transport were more likely to receive high tidal volumes initially upon transfer (relative risk [RR] = 4.6; 95% confidence interval [CI], 3.3-6.5) and at 6 and 12 hours after admission (RR = 2.6; 95% CI, 1.8-3.8 and RR = 2.7; 95% CI, 1.7-4.3, respectively). Conclusion Exposure to high tidal volumes during transport is associated with high tidal volume ventilation in the ICU, even up to 12 hours after admission. This study identifies opportunities for improving patient care through the application of lung protective ventilation strategies during transport.

A 34-year-old man developed severe hypoxemia and hypercapnia due to acute respiratory distress during ventilator care after surgery with acute intracranial hemorrhage. Severe hypoxemia had not been corrected even with maximum extracorporeal membrane oxygenation (ECMO) flow and full ventilator settings. We applied a novel technique for the serial connection of two veno-venous ECMO circuits for optimal oxygen delivery and CO2 removal and could wean VV ECMO. The use of serial connection of two VV ECMO circuits may be considered worthwhile when severe hypoxemia or hypercapnia are not improved and the use of protective ventilators is not permitted.

Purpose The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes. Methods Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization. Results A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (V-T) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH(2)0, plateau pressure was 20 cmH(2)0 (IQR = 17-23), driving pressure was 12 cmH(2)0 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36-45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003-1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001-1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome. Conclusions Protective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes. Funding Agencies|Universita degli Studi di Genova; Swedish Research Council [Vetenskapsradet]; Swedish Heart-Lung Foundation; Stig and Ragna Gorthon Foundation; Knutsson Foundation; Laerdal Foundation; Hans-Gabriel and Alice Trolle-Wachtmeister Foundation for Medical Research; Region Skane; Swedish National Health Service

Coronavirus disease 2019 (COVID-19) is a public health emergency caused by SARS-CoV-2. A few studies reported pneumothorax in patients with COVID-19. Pneumothorax is associated with an increased morbidity and mortality. Hence, it should be considered during the treatment and follow-up of patients with COVID-19. Herein, we reported four cases of pneumothorax in critical COVID-19 patients hospitalized in the ICU and treated with a mechanical ventilation. All patients were diagnosed with COVID-19, type 1 respiratory failure, and acute respiratory distress syndrome. All patients developed pneumothorax during mechanical ventilation, although the ventilator settings were set to lung-protective strategy.

To investigate whether tracheostomy placement in infants requiring high ventilator pressure is safe and effective.Case series with chart review.Tertiary children's hospital.Fifty ventilator-dependent neonatal intensive care unit patients who underwent tracheotomy from 2009 to 2018 were included. Patients requiring high ventilator pressures were compared to those requiring low ventilator pressures. Demographics, comorbidities, and surgical and clinical data were recorded.Thirty-two percent (n = 16) had low ventilator settings at the time of tracheostomy tube placement, and 68% (n = 34) had high ventilator settings. The median peak inspiratory pressure of the high ventilator group was 29.5 cm HFew differences in tracheostomy tube placement outcomes were observed for patients with high ventilator settings compared to low ventilator settings. These data demonstrate that patients requiring high ventilator pressures can benefit from tracheostomy tube placement with no additional short-term risks.

In mechanically ventilated patients, some lung injuries can be reduced or avoided with therapy individualization, while the lung function is evaluated continuously, breath by breath. However, obtaining information on respiratory mechanics (respiratory system resistance and compliance) in the presence of respiratory effort is challenging, even if using invasive and complex procedures. The contribution of this work is to predict both respiratory system resistance and compliance over time using a convolutional neural network (CNN) and estimate the respiratory effort profile using the respiratory dynamics. Therefore, the approach used in this work was to generate a large amount of simulated data to feed a CNN so it could learn how to predict the correct values of the respiratory system resistance and compliance. Then, the respiratory effort was estimated by solving a first-order linear model. The main results showed a normalized mean squared error of 5.7% for the respiratory system resistance and 11.56% for compliance from Bland-Altman plots derived from the computational simulator. Finally, the method was validated using real data from an active lung simulator within which respiratory mechanics varied, and some ventilator settings were adjusted to mimic actual patient situations. The active lung simulator effort profile was obtained with a normalized mean squared error of 8.31% considering the use of an active lung simulator. The results have shown that the simulated data were valuable for the CNN training, while the performance over the real data suggested that the network was generalized accordingly for estimating respiratory parameters and effort profile.

Background Arterial blood gas (ABG) analysis is a common test ordered in critically ill patients. Often, it is performed very frequently without influencing patient care. Hence, we decided to check the utility of the ABG test in our intensive care unit (ICU). Materials and methods The data of the previous day ABGs were captured by reviewing the chart in an online pro forma which was filled by the authors. Data relating to patient's details, who ordered ABGs, reason for ordering ABGs, and did the ABG influence patient's management were entered. A total of 985 ABGs were performed in 173 patients for 2 months which was analyzed. Results Out of 985 ABGs, in 259 instances (26.29%), interventions were done after reviewing an ABG. The major interventions among these ABGs were ventilator settings adjustment in 134 ABGs (13.6%). A total of 790 ABGs were done routinely with no specific indication (80.20%), while doctors ordered one following an event for 195 ABGs (19.80%). Conclusion Our data suggest that 80% of ABG tests were ordered as part of a routine test. How to cite this article Chandran J, D'Silva C, Sriram S, Krishna B. Clinical Utility of Arterial Blood Gas Test in an Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2021;25(2):172–175.

BACKGROUND: This study compared 3 nebulizer technologies for inter- and intradevice reproducibility, humidification, and fill volume sensitivity during mechanical ventilation: a breath-enhanced jet nebulizer, a vibrating mesh nebulizer, and a jet nebulizer. The breath-enhanced jet nebulizer featured a new design located on the wet side of the humidifier to reduce aerosol loss and potential humidifier contamination. The vibrating mesh nebulizer and the jet nebulizer were placed on the dry side. METHODS: Aerosol delivery was measured using multiple ventilator settings (inspiratory time = 0.45–1.01 s). Using radiolabeled saline and a gamma camera, bench studies were performed using a ventilator to test 4 breathing patterns. Four scenarios were assessed during testing: 3 mL and 6 mL fill volumes with and without heated wire humidification. Measurements included inhaled mass (as a percentage of the nebulizer charge), nebulizer residual, mass balance, and aerosol particle size distribution. Statistics were determined using Mann-Whitney and linear regression. RESULTS: The inhaled mass for the breath-enhanced jet nebulizer was 10.5–29.2% and was affected by fill volume (P = .004) but not by humidity. The inhaled mass for the vibrating mesh nebulizer was 0.9–33% and was unaffected by fill volume and humidity. The inhaled mass for the jet nebulizer was 2.5–25.9% and was affected by both fill volume (P = .009) and humidity (3 mL, P = .002). The inhaled mass for the vibrating mesh nebulizer was more variable due to random failures to achieve complete nebulization, and inhaled mass correlated closely with residual mass: IM% = –0.233(Residual%) + 24.3, r2 = 0.67, P CONCLUSIONS: Nebulization with the breath-enhanced jet nebulizer was less sensitive to humidification than the jet nebulizer. Delivery via the vibrating mesh nebulizer was not predictable, with random failure to empty (55% experimental runs). All devices delivered similar particle distributions. Wet-side aerosol delivery avoids humidifier contamination, and breath-enhanced technology can ensure better control of drug delivery.

OBJECTIVE: Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (VT) and use of positive end-expiratory pressures (PEEP) are increasingly used in critically ill patients. It is uncertain whether ventilation practices changed in a similar way in burn patients. Our objective was to describe applied ventilator settings and their relation to development of VILI in burn patients. DATA SOURCES: Systematic search of the literature in PubMed and EMBASE using MeSH, EMTREE terms and keywords referring to burn or inhalation injury and mechanical ventilation. STUDY SELECTION: Studies reporting ventilator settings in adult or pediatric burn or inhalation injury patients receiving mechanical ventilation during the ICU stay. DATA EXTRACTION: Two authors independently screened abstracts of identified studies for eligibility and performed data extraction. DATA SYNTHESIS: The search identified 35 eligible studies. VT declined from 14 ml/kg in studies performed before to around 8 ml/kg predicted body weight in studies performed after 2006. Low-PEEP levels (

High frequency oscillatory ventilation (HFOV) is often used as a rescue strategy for neonatal lung disease. In this article we discuss our experience of using HFOV including basic ventilator settings, optimising HFOV with monitoring and how specific diseases alter management. The article is focussed on ensuring understanding and safe use of HFOV by all neonatal staff.

This article focuses on the functional features of positive-pressure ventilators, the modes of invasive and non-invasive mechanical ventilation, and the main ventilator settings. It also highlights the potential complications of mechanical ventilation, the basic principles of weaning, and the pathophysiological basis of patient-ventilator dyssynchrony.

NIV therapy is used to provide positive pressure ventilation for patients. There are protocols describing what ventilator settings to use to initialize NIV; however, the guidelines for titrating ventilator settings are less specific. We developed an advisory system to recommend NIV ventilator setting titration and recorded respiratory therapist agreement rates at the bedside. We developed an algorithm (NIV advisor) to recommend when to change the non-invasive ventilator settings of IPAP, EPAP, and FiO2 based on patient respiratory parameters. The algorithm utilized a multi-target approach; oxygenation, ventilation, and patient effort. The NIV advisor recommended ventilator settings to move the patient's respiratory parameters in a preferred target range. We implemented a pilot study evaluating the usability of the NIV advisor on 10 patients receiving critical care with non-invasive ventilation (NIV). Respiratory therapists were asked their agreement on recommendations from the NIV advisor at the patient's bedside. Bedside respiratory therapists agreed with 91% of the ventilator setting recommendations from the NIV advisor. The POB and VT values were the respiratory parameters that were most often out of the preferred target range. The IPAP ventilator setting was the setting most often considered in need of changing by the NIV advisor. The respiratory therapists agreed with the majority of the recommendations from the NIV advisor. We consider the IPAP recommendations informative in providing the respiratory therapist assistance in targeting preferred POB and Vt values, as these values were frequently out of the target ranges. This pilot implementation was unable to produce the results required to determine the value of the EPAP recommendations. The FiO2 recommendations from the NIV advisor were treated as ancillary information behind the IPAP recommendations.

ObjectivesTo evaluate whether early intensive care transthoracic echocardiography (TTE) can improve the prognosis of patients with mechanical ventilation (MV).DesignA retrospective cohort study.SettingPatients undergoing MV for more than 48 hours, based on the Medical Information Mart for Intensive Care III (MIMIC-III) database and the eICU Collaborative Research Database (eICU-CRD), were selected.Participants2931 and 6236 patients were recruited from the MIMIC-III database and the eICU database, respectively.Primary and secondary outcome measuresThe primary outcome was in-hospital mortality. Secondary outcomes were 30-day mortality from the date of ICU admission, days free of MV and vasopressors 30 days after ICU admission, use of vasoactive drugs, total intravenous fluid and ventilator settings during the first day of MV.ResultsWe used propensity score matching to analyse the association between early TTE and in-hospital mortality and sensitivity analysis, including the inverse probability weighting model and covariate balancing propensity score model, to ensure the robustness of our findings. The adjusted OR showed a favourable effect between the early TTE group and in-hospital mortality (MIMIC: OR 0.78; 95% CI 0.65 to 0.94, p=0.01; eICU-CRD: OR 0.76; 95% CI 0.67 to 0.86, pConclusionsEarly application of critical care TTE during MV is beneficial for improving in-hospital mortality. Further investigation with prospectively collected data is required to validate this relationship.

Pendelluft phenomenon is defined as the displacement of gas from a more recruited nondependent (ND) lung region to a less recruited dependent (D) lung region. This phenomenon may cause lung injury. Thus, a lung model for pendelluft was established, and the effects of ventilatory settings on pendelluft were examined.Two sets of the twin-bellows-type training test lung (TTL) model were utilized. One set of bellows simulated the diaphragm, and the other simulated the lung. One TTL model represented the ND region, and the other represented the D region. The lung bellows were connected to each other and were ventilated with 1 ventilator. The diaphragm bellows were ventilated with 2 synchronized ventilators that regulated pleural pressure levels. We simulated pendelluft by applying different pleural pressure levels to the D and ND bellows. The increment of the tidal volume in the D region from the "no breathing effort" condition was defined as the pendelluft volume. The effects of ventilator settings, such as ventilatory modes, triggering sensitivity, inspiratory pressurization, and inspiratory cycling-off, were examined. The changes in tidal volumes in the D region based on the control settings were compared to assess the severity of pendelluft.The gas flow from the D region to the ND region was found to be essential in pendelluft, but the severity of this phenomenon was not always proportional to gas flows. The severity increased with the increase in the differences in pleural pressure levels between the ND and D regions, and it was amplified by the difference in lung mechanics between the ND and D regions. However, the ventilator settings had minimal effect on the severity of pendelluft.The pendelluft was affected by the heterogeneity of lung mechanics and pleural pressure. Furthermore, a minimal association was observed between the ventilator settings and the severity of pendelluft.

Vjollca Shpata,1 Manika Kreka,1,2 Klejda Tani1 1Faculty of Medical Technical Sciences, University of Medicine, Tirana, Albania; 2University Hospital Center “Mother Theresa”, Tirana, AlbaniaCorrespondence: Vjollca ShpataFaculty of Medical Technical Sciences, University of Medicine, Street of Dibra, Tirana, AlbaniaTel +355 69 26 35 004Fax +355 42 465298Email vjollca.hajro@yahoo.comIntroduction: Although physiotherapy is beneficial to intensive care unit (ICU) patients and recommended by guidelines, the role of physiotherapy in ICU settings is not fully explored in Albania.Purpose: To provide an overview of the current physiotherapy practice in Albanian ICUs and explore the involvement of physiotherapists and intensive care nurses regarding respiratory therapy and early mobility in the ICU.Patients and Methods: This was an observational cross-sectional study, which included all ICU nurses working in six ICUs of University Hospital Center “Mother Theresa” and University Hospital of Trauma and all physiotherapists working in these hospitals. ICU nurses and hospital physiotherapists were approached to complete the survey regarding respiratory therapy and early mobility in critically ill patients.Results: One hundred thirty-one completed questionnaires were returned from 189 questionnaires distributed to the survey participants (151 nurses and 38 physiotherapists); the response rate was 69.3%. Physiotherapy procedures were performed on a non-regular basis in ICUs in Tirana, Albania. Physiotherapists were not actively involved or exclusively employed in the ICU, and these ICUs did not use protocols for physiotherapist consultation. Physiotherapists occasionally performed respiratory therapy and early mobility in patients without an artificial airway. Nursing staff regularly performed airway suctioning in mechanically ventilated patients (100%) and participated in adjusting ventilator settings (82.2% regularly and 17.8% occasionally). In contrast, physiotherapists did not participate in these procedures and the early mobility of mechanically ventilated patients.Conclusion: We report limited physiotherapy involvement in Albanian ICUs. Efforts should focus on improving physiotherapy practice in ICU, potentially making organizational and cultural changes in the ICU, and establishing protocols and guidelines.Keywords: intensive care unit, physiotherapy, nurse, physiotherapist, critical patients care

Introduction-A significant number of intubated COVID-19 patients may develop worrisome hemorrhage related to trachea-bronchial mucosal and submucosal slough due to severe inflammation/necrosis related to COVID-19 pneumonia. The accumulation of debris in the endotracheal tube can progress to severe endotracheal tube obstruction ( ETO) necessitating high peak driving pressures with eventual loss of satisfactory ventilator volume delivery. Emergency endotracheal tube exchange under these circumstances can be an extremely high-risk undertaking both for the patient and caregivers. Method-Thirty mechanically ventilated COVID-19 patients deemed at high risk for ETO or who had already had a prior episodes of ETO were selected as candidates for bedside percutaneous tracheostomy. Those patients requiring high ventilator settings high ventilator ( i.e. FIO2 > 50 and PEEP more than 10 ) were also included in the study group. A disposable bronchoscope was utilized for direct visualization of appropriate tracheal puncture, guidewire passage, and final positioning of the tracheal tube. Results-All patients, including those individuals on high ventilator support attained the primary outcome of successful percutaneous tracheostomy without serous adverse events. Minor adverse events, such as brief periods of oxygen desaturation, were observed in 3 patients. Conclusion-Bedside percutaneous tracheostomy is a safe therapeutic option for patients with high risk for ETO due to trachea-bronchial mucosal and submucosal slough. Consideration for early, elective intervention may be justified due to high risks associated with urgent/emergency endotracheal tube exchange.

BACKGROUND: We sought to describe adverse events associated with unplanned extubation (UE) and to explore risk factors for serious adverse events post-UE among infants who experienced UE. METHODS: Data were prospectively collected on all infants who had a UE event at a single institution over a 4-y period. Demographic information and information on outcomes were obtained retrospectively. We described the frequency of post-UE adverse events: success or failure of extubation trial if offered, rate of re-intubation, post-UE changes in ventilator settings, and serious adverse events post-UE (eg, need for cardiopulmonary resuscitation, clinical sepsis, and death or tracheostomy prior to discharge). We used a multivariate logistic regression model to identify the risk factors associated with serious adverse events. RESULTS: There were 134 documented UE events. Agitation was the most common known cause. After UE, 49% of the subjects were given a trial of extubation, and 65% of the trials were successful at 48 h. Cardiopulmonary resuscitation (CPR) was performed in 13% of cases. In subjects requiring immediate re-intubation, mean airway pressure (Paw) and oxygen requirement increased in 33% and 55% of the subjects, respectively. Post-UE clinical sepsis occurred in 17% of subjects. Higher pre-UE Paw and difficult re-intubation were associated with a need for CPR. Subjects who received CPR had increased odds (3.7×) of developing clinical sepsis. CONCLUSION: UE can result in serious adverse events, including hemodynamic instability and possibly an increased risk for clinical sepsis. Difficult re-intubation was associated with a higher risk of needing CPR and, later, tracheostomy and death.

Background Ventilator hyperinflation (VHI) is effective in improving respiratory mechanics, secretion removal, and gas exchange in mechanically ventilated subjects; however, there are no recommendations for the best ventilator settings to perform the technique. Objective To compare six modes of VHI, concerning physiological markers of efficacy and safety criteria to support the selection of optimal settings. Methods Thirty mechanically ventilated patients underwent six modes of VHI in a randomized order. The delivered volume, expiratory flow bias criteria, overdistension, patient–ventilator asynchronies and hemodynamic variables were assessed during the interventions. Results Volume-controlled ventilation with inspiratory flow of 20 lpm (VC-CMV20) and pressure support ventilation (PSV) achieved the best effectiveness scores (P Conclusions The modes VC-CMV20 and PSV are the most effective for VHI. Alveolar overdistension and patient–ventilator asynchronies must be considered when applying VHI.

Patients with end-stage chronic obstructive pulmonary disease (COPD) frequently develop chronic hypercapnic respiratory failure (CHRF), with disabling symptoms and poor survival. The use of long-term nocturnal non-invasive ventilation (NIV) to treat CHRF in COPD has long been subject of debate due to conflicting evidence. However, since the introduction of high-intensity NIV (HI-NIV) in COPD, physiological and clinical benefits have been shown. HI-NIV refers to specific ventilator settings used for NIV aimed at achieving normocapnia or the lowest partial arterial carbon dioxide pressure (PaCO 2 ) values as possible. This review will provide an overview of existing evidence of the efficacy of HI-NIV stable COPD patients with CHRF. Secondly, we will discuss hypotheses underlying NIV benefit in stable hypercapnic COPD, providing insight into better patient selection and hopefully more individually titrated HI-NIV. Finally, we will provide practical advice on how to initiate and follow-up patients on HI-NIV, with special emphasis on monitoring that should be available during the initiation and follow-up of HI-NIV, and will discuss more extended monitoring techniques that could improve HI-NIV treatment in the future.

Background and Objectives: Extubation failure in preterm infants is associated with increased risk of mortality and morbidities. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status. Methods: This was a retrospective study of infants with birth weight ≤1,250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score and ventilation index were used to assess respiratory status of infants. Results: Of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77% and 56% infants remained intubated at 24 hours, 72 hours and 7 days, respectively. Respiratory status was worse at 24 hours and 72 hours after re-intubation when compared to pre-extubation levels. The median times for respiratory severity score and ventilation index to reach pre-extubation levels were 4 days and 7 days respectively. Conclusion: Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.

BACKGROUND: Pendelluft phenomenon is defined as the displacement of gas from a more recruited nondependent (ND) lung region to a less recruited dependent (D) lung region. This phenomenon may cause lung injury. Thus, a lung model for pendelluft was established, and the effects of ventilatory settings on pendelluft were examined. METHODS: Two sets of the twin-bellows-type training test lung (TTL) model were utilized. One set of bellows simulated the diaphragm, and the other simulated the lung. One TTL model represented the ND region, and the other represented the D region. The lung bellows were connected to each other and were ventilated with 1 ventilator. The diaphragm bellows were ventilated with 2 synchronized ventilators that regulated pleural pressure levels. We simulated pendelluft by applying different pleural pressure levels to the D and ND bellows. The increment of the tidal volume in the D region from the “no breathing effort” condition was defined as the pendelluft volume. The effects of ventilator settings, such as ventilatory modes, triggering sensitivity, inspiratory pressurization, and inspiratory cycling-off, were examined. The changes in tidal volumes in the D region based on the control settings were compared to assess the severity of pendelluft. RESULTS: The gas flow from the D region to the ND region was found to be essential in pendelluft, but the severity of this phenomenon was not always proportional to gas flows. The severity increased with the increase in the differences in pleural pressure levels between the ND and D regions, and it was amplified by the difference in lung mechanics between the ND and D regions. However, the ventilator settings had minimal effect on the severity of pendelluft. CONCLUSIONS: The pendelluft was affected by the heterogeneity of lung mechanics and pleural pressure. Furthermore, a minimal association was observed between the ventilator settings and the severity of pendelluft.

Respiratory monitoring is essential during both noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) of critically ill patients. While patients are treated, ventilator requirements get changed. Therefore, ventilator settings must be reviewed through close monitoring of clinical parameters and ventilator parameters of the patients to meet their new criteria and prevent ventilator-induced lung injury (VILI). While on NIV, more parameters must be monitored to early predict NIV failure for the decision of intubation or assess weanability as soon as possible. Moreover, some technical issues must be applied to optimize ventilation settings before considering NIV failure. Once patient clinical parameters/lung functions get normalized, a weaning plan could be started safely. The purpose of this chapter is to review the respiratory monitoring plans, methods for optimizing ventilator settings, and possible weaning plans for critically ill patients.

Background: Mechanical ventilation is a lifesaving therapy for critically ill patients. Hospitals perform surveillance for the NHSN for ventilator-associated events (VAE) by monitoring mechanically ventilated patients for metrics that are generally thought to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner; initially, a ventilator-associated condition (VAC) is triggered with an increase in positive end-expiratory pressure (PEEP, >3 cm H2O) or fraction of inspired oxygen (FIO2, 0.20 or 20 points) after a period of stability or improvement on the ventilator. We believe that many reported VAEs could be avoided by provider and respiratory therapy attention to “knobmanship.” We define knobmanship as knowledge of the VAE definition and trigger points combined with appropriate clinical care for mechanically ventilated patients while avoiding unnecessary triggering of the VAE definition by avoiding small unneeded changes in PEEP or FIO2. Methods: We performed a chart review of 283 patients who had a reported VAE to the NHSN between January 1, 2019, and December 31, 2020. We collected data including type of VAE, VAE triggering criteria, and clinical course. Results: Of the 283 VAEs, 59 were triggered by a PEEP increase from 5 to 8 with stable or decreasing FIO2. Of the 59 VAEs, 33 were VACs, 18 were infection-related ventilator- associated complications (IVACs), and 8 were possible ventilator-associated pneumonia (PVAP). Most of these transient changes in PEEP were deemed clinically unnecessary. A 21% reduction of VAEs reported to the NSHN over the 2-year review period could have been avoided by knobmanship. Conclusions: The VAE definition may often be triggered by provider bias to the ventilator settings rather than what the patient’s clinical-condition requires. Attention to knobmanship may result in substantial decrease in reported VAE.Funding: NoDisclosures: None

Background: Noninvasive ventilation (NIV) is accepted as standard of care for chronic hypercapnic respiratory failure (CHRF) and is being increasingly implemented in older subjects. However, little is known regarding the use of NIV on a long-term basis in the very old. The outcomes of this study were: 1/to report the proportion of patients ≥ 75 years old (elderly) among a large group of long-term NIV users and its trend since 2000; 2/to compare this population to a younger population (2 : 5.8 vs. 5.9 kPa, p = 0.968). Unintentional leaks were slightly higher in the older group (1.8 vs. 0.6 L/min, p = 0.018). Conclusions: In this cross-sectional study, one third of the population under NIV was ≥ 75 years old. Markers of efficacy of NIV, and adherence to treatment were similar when compared to younger subjects, confirming the feasibility of long-term NIV in the very old. Health-related quality of life was not assessed in this study and further research is needed to address this issue.

BACKGROUND: Little is known to what extent attitudes of ICU clinicians are influenced by new insights and recommendations to be more conservative with oxygen therapy. Our aim was to investigate whether implementation of a conservative oxygenation guideline structurally changed self-reported attitudes and actual clinical practice. METHODS: After the implementation of a conservative oxygen therapy guideline in 3 teaching hospitals in the Netherlands, ICU clinicians were surveyed regarding their attitudes toward oxygen therapy. The survey results were compared with survey results taken before the introduction of the new guideline. Arterial blood gas analysis data and ventilator settings were retrieved from all patients admitted to the participating ICUs in the studied period, and changes after implementing the guideline were assessed. RESULTS: In total, 180 ICU clinicians returned the survey. Compared to before implementation of a conservative oxygen guideline, more clinicians chose a preferred P aO 2 and an oxygen saturation measured from an arterial sample ( S aO 2 ) limit after implementation of the guideline. In general, clinicians reported a more conservative approach toward management of F IO 2 and less frequently increased the F IO 2 . In the period after the active implementation of the guideline, 5,840 subjects were admitted to the participating ICUs and 101,869 arterial blood gas analyses were retrieved. Actual practice changed with overall lower oxygenation levels (median P aO 2 77.93 mm Hg, compared to 86.93 mm Hg before implementation) of arterial blood and a decrease of PEEP and F IO 2 . CONCLUSIONS: Implementing a conservative oxygenation guideline was an effective method that changed self-reported attitudes and actual clinical practice and improved adherence to conservative oxygenation targets in a short period of time.

The administration of drugs and fluid, most of which are given as the dose per kg of body weight, is a vital component in the management of the seriously injured child. Obtaining an accurate weight on arrival may not be immediately achievable because of instability, immobilisation and ongoing resuscitation. The paediatric STAG (Scottish trauma audit group) data from * hospital was used to identify patients over 12 months. Clinical notes were reviewed to assess if weight was estimated or accurately measured. 56 paediatric trauma patients who met the STAG inclusion criteria presented to * over the 12 month period. 27/56 (48%) patients had an estimated weight on arrival; 5 were estimated using the ‘old’ APLS formula, 12 using the ‘new’ formulae and for the remaining 10 the method used was unclear. Of those who initially had an estimated weight only 7/27 (26%) went on to have an accurate weight obtained at any time during their admission. In 5 patients, weight was underestimated (mean -12%) and in 2 patients, weight was overestimated (mean +19%). The weight estimation error ranged from negative 28% to positive 20%. Assessing the percentage error of estimated weight was challenging in this group of patients due to the small number on which an accurate weight was measured during this admission. Poor documentation may have been a contributing factor in some cases with the weight on a patient’s drug kardex only being clearly identified as being an ‘estimated’ value in 66% of patients. There are many implications of using an estimated weight, including errors in drug doses, fluid bolus, maintenance fluids, ventilator settings and assessment of urine output. In this cohort the estimated weight that followed them throughout their admission has implications on their immediate resuscitation and extended inpatient care and highlights the importance of obtaining an accurate weight at the time of arrival. What can we do differently? We have implemented the use of a pat-slide weighing scale by MARSDEN to get an accurate weight from time of arrival. This device enables a rapid weight to be obtained during patient transfer to the trolley.