Gilles Hilbert

Prone Positioning in Severe Acute Respiratory Distress Syndrome

BACKGROUND Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes. We evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. METHODS In this multicenter, prospective, randomized, controlled trial, we randomly assigned 466 patients with severe ARDS to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of less than 150 mm Hg, with an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion. RESULTS A total of 237 patients were assigned to the prone group, and 229 patients were assigned to the supine group. The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P<0.001). The hazard ratio for death with prone positioning was 0.39 (95% confidence interval [CI], 0.25 to 0.63). Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group. CONCLUSIONS In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique National 2006 and 2010 of the French Ministry of Health; PROSEVA ClinicalTrials.gov number, NCT00527813.).

Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and Acute Respiratory Failure

BACKGROUND Avoiding intubation is a major goal in the management of respiratory failure, particularly in immunosuppressed patients. Nevertheless, there are only limited data on the efficacy of noninvasive ventilation in these high-risk patients. METHODS We conducted a prospective, randomized trial of intermittent noninvasive ventilation, as compared with standard treatment with supplemental oxygen and no ventilatory support, in 52 immunosuppressed patients with pulmonary infiltrates, fever, and an early stage of hypoxemic acute respiratory failure. Periods of noninvasive ventilation delivered through a face mask were alternated every three hours with periods of spontaneous breathing with supplemental oxygen. The ventilation periods lasted at least 45 minutes. Decisions to intubate were made according to standard, predetermined criteria. RESULTS The base-line characteristics of the two groups were similar; each group of 26 patients included 15 patients with hematologic cancer and neutropenia. Fewer patients in the noninvasive-ventilation group than in the standard-treatment group required endotracheal intubation (12 vs. 20, P=0.03), had serious complications (13 vs. 21, P=0.02), died in the intensive care unit (10 vs. 18, P=0.03), or died in the hospital (13 vs. 21, P=0.02). CONCLUSIONS In selected immunosuppressed patients with pneumonitis and acute respiratory failure, early initiation of noninvasive ventilation is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge.

Strategy of antibiotic rotation: long-term effect on incidence and susceptibilities of Gram-negative bacilli responsible for ventilator-associated pneumonia.

ObjectiveTo evaluate the long-term effect of a program of rotating antibiotics on the incidence of ventilator-associated pneumonia and the susceptibilities of Gram-negative bacilli responsible for ventilator-associated pneumonia. DesignProspective program for the surveillance of antibiotic susceptibilities of microorganisms responsible for ventilator-associated pneumonia. SettingAcademic, university-based, medical intensive care unit (16 beds). Subjects2,856 mechanically ventilated patients. InterventionsA new program of antibiotic use was introduced at the end of 1996 that involved the rotation of antibiotics in empirical and therapeutic use of the treatment of ventilator-associated pneumonia. The rotation concerned the &bgr;-lactam and aminoglycoside classes, with a rotation interval of 1 month. The use of antibiotics was monitored monthly. No preference was given to any particular antibiotic. In a previous study, the period before the introduction of this protocol (1995–1996) was compared with the period 2 yrs after (1997–1998): The results indicated a decreased incidence of ventilator-associated pneumonia, a lower incidence of potentially resistant Gram-negative bacilli, and increased sensitivities of Gram-negative bacilli, especially Pseudomonas aeruginosa and Burkholderia cepacia. After 1998, we decided to continue a routine for this rotation. The long-term effect of this program was studied by comparing the incidence of Gram-negative bacilli responsible for ventilator-associated pneumonia and their susceptibilities obtained in a third period: 1999–2001. The long-term effect (5 yrs) of such a strategy—2-yr protocol period (1997–1998) and 3-yr routine period (1999–2001)—could be evaluated. Measurements and Main ResultsDuring the 7-yr study period, 2,856 patients were mechanically ventilated for >48 hrs. The incidence of ventilator-associated pneumonia remained significantly lower in period 3 (1999–2001): 23% (period 1, 1995–1996) vs. 15.7% (period 2, 1997–1998) vs. 16.3% (period 3, 1999–2001; p = .002). Late-onset ventilator-associated pneumonia occurred in 86.6% and 94% of cases, respectively, in periods 1 and 3 (p = .02). The decrease of the incidence of early-onset ventilator-associated pneumonia was statistically significant during the 7-yr study period: 13% vs. 9% vs. 5.9% (p = .02). Combined with a higher incidence of late-onset ventilator-associated pneumonia, the incidence of potentially resistant Gram-negative bacilli increased in period 3: 42.2% vs. 34.5% vs. 41.7% (nonsignificant), except for B. cepacia: 11.7% vs. 7.4% vs. 3.7% (p = .005). Nevertheless, the potential antibiotic-resistant Gram-negative bacilli were more sensitive to most of the &bgr;-lactams, especially piperacillin-tazobactam and cefepime. ConclusionsRotation of antibiotics could help to avoid ventilator-associated pneumonia. It could greatly improve the susceptibilities of the potentially antibiotic-resistant Gram-negative bacilli responsible for late-onset ventilator-associated pneumonia. This program could be applied in routine with good results 5 yrs after its introduction. Further studies, especially multiple-center trials, are necessary to confirm this result and better define the rotation type and intervals.

Noninvasive continuous positive airway pressure in neutropenic patients with acute respiratory failure requiring intensive care unit admission.

ObjectiveTo evaluate the tolerance and the efficacy of noninvasive continuous positive airway pressure (CPAP) in severe acute respiratory failure occurring in intensive care unit (ICU) neutropenic patients with hematologic malignancies, and to establish predictive variables of efficacy of this method. DesignProspective study over a 5-yr period. SettingHematologic and medical intensive care unit of a teaching hospital. MethodsAmong 129 neutropenic patients admitted to the ICU, 64 patients presented with febrile acute hypoxemic normocapnic respiratory failure (Pao2/Fio2 ratio <200) and were enrolled. In addition to standard therapy, patients received CPAP with a facial mask. The initial settings of the CPAP were 6 cm H2O positive end-expiratory pressure and Fio2 0.8 (80%). Physiologic measurements were performed at the end of 45 mins of ventilation with first adjustments. CPAP was used with a sequential mode (45 mins/3 hrs). CPAP was efficient if intubation was avoided. ResultsThe setting of CPAP, after adjustments, was as follows: positive end-expiratory pressure 7 ± 1 cm H2O and Fio2 0.7 ± 0.1 (70% ± 10%). For the 64 patients, CPAP was administered for a total of 6 ± 2 hrs during the first 24 hrs. The mean duration of CPAP was 7 ± 3 days. A reduction in respiratory rate to less than 25 breaths/min was achieved in 53% of patients. Pao2/Fio2 ratio increased from 128 ± 32 to 218 ± 28. CPAP was successful in avoiding endotracheal intubation in 16/64 patients. A total of 16 responders and four nonresponders survived. Hepatic failure was a criterion indicating the failure of CPAP1/16 vs. 26/48 (p = .001). In multivariate analysis, two variables were predictive of failure of CPAPSimplified Acute Physiology Score II (58 ± 14 vs. 41 ± 11) and a hepatic failure at the entry into the study. ConclusionCPAP was efficient in 25% of cases. All the responders survived. This noninvasive method was used as a way to avoid mechanical ventilation, which is well correlated with a poor prognosis in neutropenic ICU patients. Further controlled studies are needed to confirm the efficacy of noninvasive CPAP and to evaluate the most appropriate selection of immunocompromised patients.

Utility of fiberoptic bronchoscopy in neutropenic patients admitted to the intensive care unit with pulmonary infiltrates.

Objective To analyze the impact of fiberoptic bronchoscopy and bronchoalveolar lavage (BAL) on guiding the treatment and intensive care unit (ICU) clinical outcome in neutropenic patients with pulmonary infiltrates admitted to the ICU. Design Prospective collection of data. Setting Medical ICU in a teaching hospital. Patients During a 6-yr period, we analyzed the results of 93 fiberoptic bronchoscopies plus BALs performed in 93 consecutive neutropenic ICU patients. We separated the patients into two groups according to the cause of neutropenia (high-dose chemotherapy [n = 41] or stem cell transplantation [SCT; n = 52]). Results Of the 93 BALs, 53 were performed to evaluate diffuse infiltrates and 42 were performed on mechanically ventilated patients. Forty-nine percent of BALs (46 patients) were diagnostic, with a significantly better yield in ICU patients with high-dose chemotherapy-induced neutropenia (26 of 41 BALs). The number of cases of proven infectious pneumonia was significantly higher in this group of ICU neutropenic patients. In patients who underwent SCT, diffuse infiltrates were statistically correlated with a negative result of BAL. Twenty-six patients who underwent diagnostic BALs changed therapy. Sixteen complications (17%) occurred with only two intubations. The overall mortality rate in the ICU and the mortality rate in mechanically ventilated neutropenic patients were 71% and 93%, respectively. In neutropenic patients who underwent SCT, the mortality rate was statistically higher in patients in whom no diagnosis was established. Patients who had a diagnostic BAL that changed therapy did not have an increased probability of survival compared with patients who had a BAL that did not change therapy. Conclusions The use of routine diagnostic BAL in ICU neutropenic patients with pulmonary infiltrates is difficult to establish, even if BAL is helpful in the management of these critically ill patients. BAL in our ICU neutropenic patient population had an acceptable overall diagnostic yield (49%), which was higher in ICU patients with chemotherapy-induced neutropenia. Nevertheless, in the ICU, if BAL had a low complication rate, it had infrequently led to changed treatment and was not associated with improved patient survival.

Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial.

RATIONALE The use of noninvasive ventilation (NIV) as an early weaning/extubation technique from mechanical ventilation remains controversial. OBJECTIVES To investigate NIV effectiveness as an early weaning/extubation technique in difficult-to-wean patients with chronic hypercapnic respiratory failure (CHRF). METHODS In 13 intensive care units, 208 patients with CHRF intubated for acute respiratory failure (ARF) who failed a first spontaneous breathing trial were randomly assigned to three groups: conventional invasive weaning group (n = 69), extubation followed by standard oxygen therapy (n = 70), or NIV (n = 69). NIV was permitted as rescue therapy for both non-NIV groups if postextubation ARF occurred. Primary endpoint was reintubation within 7 days after extubation. Secondary endpoints were: occurrence of postextubation ARF or death within 7 days after extubation, use of rescue postextubation NIV, weaning time, and patient outcomes. MEASUREMENTS AND MAIN RESULTS Reintubation rates were 30, 37, and 32% for invasive weaning, oxygen-therapy, and NIV groups, respectively (P = 0.654). Weaning failure rates, including postextubation ARF, were 54, 71, and 33%, respectively (P < 0.001). Rescue NIV success rates for invasive and oxygen-therapy groups were 45 and 58%, respectively (P = 0.386). By design, intubation duration was 1.5 days longer for the invasive group than in the two others. Apart from a longer weaning time in NIV than in invasive group (2.5 vs. 1.5 d; P = 0.033), no significant outcome difference was observed between groups. CONCLUSIONS No difference was found in the reintubation rate between the three weaning strategies. NIV decreases the intubation duration and may improve the weaning results in difficult-to-wean patients with CHRF by reducing the risk of postextubation ARF. The benefit of rescue NIV in these patients deserves confirmation.

Intrapulmonary percussive ventilation in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled trial [ISRCTN17802078]

IntroductionWe hypothesized that the use of intrapulmonary percussive ventilation (IPV), a technique designed to improve mucus clearance, could prove effective in avoiding further deterioration in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) with mild respiratory acidosis.MethodsThe study was performed in a medical intensive care unit of a university hospital. Thirty-three patients with exacerbations of COPD with a respiratory frequency ≥ 25/min, a PaCO2 > 45 Torr and 7.35 ≤ pH ≤ 7.38 were included in the study. Patients were randomly assigned to receive either standard treatment (control group) or standard treatment plus IPV (IPV group). The IPV group underwent two daily sessions of 30 minutes performed by a chest physiotherapist through a full face mask. The therapy was considered successful when both worsening of the exacerbation and a decrease in pH to under 7.35, which would have required non-invasive ventilation, were avoided.ResultsThirty minutes of IPV led to a significant decrease in respiratory rate, an increase in PaO2 and a decrease in PaCO2 (p < 0.05). Exacerbation worsened in 6 out of 17 patients in the control group versus 0 out of 16 in the IPV group (p < 0.05). The hospital stay was significantly shorter in the IPV group than in the control group (6.8 ± 1.0 vs. 7.9 ± 1.3 days, p < 0.05).ConclusionIPV is a safe technique and may prevent further deterioration in patients with acute exacerbations of COPD with mild respiratory acidosis.

Sequential use of noninvasive pressure support ventilation for acute exacerbations of COPD

Objectives: To compare the efficacy of noninvasive pressure support ventilation (NIPSV) in acute decompensation in chronic obstructive pulmonary disease (COPD) by means of a bi-level positive airway pressure support system (BiPAP) in a sequential mode with medical therapy alone; to assess the short-term physiologic effects of the device on gas exchange; and to compare patients successfully ventilated with NIPSV with those in whom NIPSV failed. Design: A prospective case series with historically matched control study. Setting: A general intensive care unit (ICU) of a university hospital. Patients: We evaluated the efficacy of administration of NIPSV in 42 COPD patients and compared this with standard treatment in 42 matched historical control COPD patients. Interventions: NIPSV was performed in a sequential mode, i. e., BiPAP in the spontaneous mode was used for at least 30 min every 3 h. Between periods of ventilation, patients could be systematically returned to BiPAP when the arterial oxygen saturation was < 0.85 or when the respiratory rate was > 30 breaths/min. Measurements and results: Success rate, mortality, duration of ventilatory assistance, and length of ICU stay were recorded. Eleven of the 42 patients (26 %) in the NIPSV group needed tracheal intubation compared with 30 of the 42 control patients (71 %). The 31 patients in whom NIPSV was successful were ventilated for a mean of 6 ± 3 days. In-hospital mortality was not significantly different in the treated versus the control group, but the duration of ventilatory assistance (7 ± 4 days vs 15 ± 10 days, p < 0.01) and the length of ICU stay (9 ± 4 days vs 21 ± 12, p < 0.01) were both shortened by NIPSV. BiPAP was effective in correcting gas exchange abnormalities. The pH values, measured after 45 min of BiPAP with optimal settings, in the success (7.38 ± 0.04) and failure (7.28 ± 0.04) patients were significantly different (p < 0.05). Conclusions: NIPSV, performed with a sequential mode, may be used in the management of patients with acute exacerbations of COPD.

Bronchoscopy with bronchoalveolar lavage via the laryngeal mask airway in high-risk hypoxemic immunosuppressed patients.

ObjectiveFiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) are major tools in the diagnosis of pulmonary complications in immunocompromised patients. Nevertheless, severe hypoxemia is an accepted contraindication to FOB in nonintubated patients. The purpose of this study was to evaluate the feasibility and safety of laryngeal mask airway (LMA)-supported FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia. DesignProspective, clinical investigation. SettingMedical intensive care unit of a university hospital. PatientsForty-six immunosuppressed patients admitted to our intensive care unit with suspected pneumonia and Pao2/Fio2 ≤ 125. InterventionsAfter the administration of 0.3 mg·kg−1 of etomidate, the patients were ventilated manually while receiving 1.0 Fio2. After the administration of 2.5 mg·kg−1 of propofol, followed by an infusion of 9.1 ± 2.3 mg·kg−1·hr−1of propofol, the LMA (size 3 or 4) was placed and connected to a bag-valve unit to allow manual ventilation with 1.0 Fio2. The FOB was introduced through a T-adapter attached to the LMA, and BAL was carried out with 150 mL of sterile 0.9% saline solution by sequential instillation and aspiration of 50-mL aliquots. Measurements and Main Results Three patients developed transient laryngospasm during passage of the bronchoscope via the LMA, which resolved with deepening of anesthesia. Changes in mean blood pressure, heart rate, Pao2/Fio2, and Paco2 values induced by the procedure did not reach significance. Seven patients (15%) presented hypotension (mean blood pressure, <60 mm Hg) maintained for 120 ± 40 secs, which required plasma expanders in three cases. Oxygen desaturation to <90% occurred in six patients (13%) during BAL. Nevertheless, the lowest Sao2 during the procedure was significantly higher than the initial Sao2 (94% ± 4% vs. 90% ± 2%). No patient required tracheal intubation during the 8 hrs after the procedure. BAL had an overall diagnostic yield of 65%. Because of the results obtained by using the BAL analysis, treatment was modified in 33 (72%) cases. ConclusionApplication of the LMA appears to be a safe and effective alternative to intubation for accomplishing FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.

Fulminant Guillain-Barré syndrome mimicking cerebral death: case report and literature review.

Abstract A 45-year-old woman was admitted to the intensive care unit (ICU) for respiratory arrest. One day prior to admission, she had been nauseated and in a state of total exhaustion. On the night of admission she was unresponsive and developed gasping respiration. The patient was comatose with absent brainstem reflexes and appeared brain dead. Blood chemistry findings and brain magnetic resonance imaging were normal. Electroencephalogram revealed an alpha rhythmical activity unresponsive to painful or visual stimuli. The cerebrospinal fluid showed an albuminocytological dissociation. Guillain-Barré syndrome (GBS) was suspected. The electrophysiological evaluation revealed an inexcitability of all nerves. The pathological findings of the sural nerve biopsy indicated an axonal degeneration secondary to severe demyelination. GBS can very rarely present with coma and absent brainstem reflexes. This case illustrates the importance of electrophysiological tests and laboratory and imaging studies in patients with suspected brain death where a cause is not clearly determined.