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Impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial

Acute respiratory insufficiency is common in the pediatric population. It is estimated that two to three million children a year worldwide die of respiratory causes (1). Undoubtedly, mechanical ventilation (MV) is an important medical intervention capable of reducing morbidity and mortality in this population, especially among severe cases (2). However, it remains a practical challenge to accurately predict when a patient is ready to sustain spontaneous breathing and successfully discontinue MV (2–5). Extubation failure, which is defined as the need for reintubation and reestablishment of MV within 48 to 72 hrs after the tracheal cannula is removed (6–10), is associated with a poor prognosis and an increased mortality rate (11, 12). In the pediatric population, extubation failure rates vary between 16% and 19% (6–9). Nevertheless, ventilation times are often extended unnecessarily. In a previous study in which 136 children underwent unplanned extubation, most of the patients did not require reintubation (12). Extended MV periods are associated with an increased risk of complications, such as nosocomial pneumonia (13–16), ventilator-induced lung injury (17, 18), airway injuries (19), and an increased need for sedatives. Thus, MV should be discontinued as soon as possible. However, successful early extubation is difficult because extubation criteria may vary. Thus, the continued search for criteria to indicate the correct time to end MV is a priority. Several previous studies conducted in the pediatric population have tried to define predictors of successful extubation. However, it has not been possible to determine which set of parameters accurately predicts successful extubation (6, 8, 9, 20). The spontaneous breathing test (SBT) was developed as an attempt to identify patients who are ready to discontinue ventilation (21, 22). The test aims at monitoring signs of respiratory muscle fatigue while the patient is still intubated. A previous study showed that SBT performed with a T-piece was able to predict successful extubation in 70% of intubated children (20). In a subsequent work, the *See also p. 2581. From the Intensive Care Unit (FKF, LSF), Hospital Sı́rio Libanês, São Paulo, Brazil; Pediatric Department (FKF, EJT, AAF, LSF, FFP, AFD), and Pneumology Department (CSB), Hospital das Clı́nicas, Medical School of São Paulo University, São Paulo, Brazil; Intensive Care Unit (EJT, AB, FFP), Hospital Albert Einstein, São Paulo, Brazil; Intensive Care Unit (JAF), Hospital de Niños R Gutiérrez, Buenos Aires University, Buenos Aires, Argentina; and Intensive Care Unit (AB), Hospital Universitário, Medical School of São Paulo University, São Paulo, Brazil. The authors have not disclosed any potential conflicts of interest. For information regarding this article, E-mail: flikrepel@foronda.com.br Copyright

Obstructive respiratory failure in cicatricial pemphigoid.

A 20 year old woman died of respiratory failure due to cicatricial pemphigoid of the trachea and bronchi. This is the first case with the lower airways affected to be reported.

Noninvasive positive pressure ventilation can prevent reintubation after acute respiratory failure: results of a prospective and randomized study

We hypothesize that the use of noninvasive positive pressure ventilation can be helpful in preventing reintubation after weaning of mechanical ventilation in patients with acute respiratory failure (ARF).

Low tidal volume in association with low positive end expiratory pressure in acute respiratory distress syndrome: a suboptimal strategy? A computed tomography-based analysis

In a recent trial, ARDSNet investigators found no benefit with the association of an intermediary PEEP to a low-tidal-volume (6 ml/kg) ventilatory strategy. The goal of maximal recruitment strategy (MRS) guided by thoracic CT scan is to minimize alveolar collapse and tidal recruitment (TR).

Flow or pressure triggering during pressure support ventilation

Pressure and flow triggering have improved greatly in the new generation of ventilators. The routine use of one or the other in adult patients in the ICU setting is not yet well established.

CO2 dynamics in ARDS patients: effects of PEEP above the Pflex

Titrating PEEP above the Pflex can improve oxygenation and survival when compared to the conventional ventilation in ARDS patients. In order to study the dynamics of CO2 in ARDS patients as well as the effects of setting PEEP above the Pflex on the CO2 dynamics we studied seven patients with ARDS criteria (less than 5 days of installation), with mean age of 63 ± 0.11 years and mean APACHE score of 21.4. After performing the PxV curve (random volumes) we ventilated the patients with 8 ml/kg TV and RR of 15 and PEEP of 5 cmH2O. Then we kept the same MV and set PEEP 2 cmH2O above Pflex for 30 min. Then we decreased PEEP to 5 for more 30 min. All the patients have a Swan-Ganz catheter and a continuous tonometer.

Maximum recruitment strategy revealed efficiency and a larger recruitable lung in a prospective series of early ARDS patients

A recent meta-analysis demonstrated that higher levels of PEEP were associated with improved survival among the subgroup of patients with ARDS. The maximum recruitment strategy (MRS) guided by thoracic CT scan is capable of reversing alveolar collapse almost completely, allowing PEEP titration to sustain lungs almost fully open, homogenizing tidal ventilation and possibly reducing ventilator-induced lung injury.

Maximal recruitment strategy guided by thoracic computed tomography scan in acute respiratory distress syndrome patients: preliminary results of a clinical study.

There is great controversy concerning protective ventilatory strategy in ARDS. Recruitment maneuvers and PEEP titration sufficient to avoid collapse and tidal recruitment in the lung are the major goals of the maximal recruitment strategy (MRS) guided by computed tomography (CT).

Influence of the pressure support slope on the respiratory parameters of intensive care unit patients

The possibility of changing the pressure slope during pressure support ventilation is a characteristic of the new generation of ICU ventilators. However, the influence of the slope changes on the respiratory parameters in ICU patients is still under investigation.

Does the cycling-off criteria of pressure support change the respiratory parameters in intensive care unit patients?

In modern mechanical ventilators it is possible to modify the flow cycling-off criteria of pressure support ventilation. The changes in the flow cycling-off criteria of pressure support ventilation can modify the synchrony between the mechanical and neural inspiration termination.