Jean Keddissi

Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy

Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.

Review and Outcome of Prolonged Cardiopulmonary Resuscitation

The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts.

422 EVALUATION OF EARLY RAPID SHALLOW BREATHING AS A PREDICTIVE WEANING INDEX FOR SUCCESSFUL EXTUBATION

Introduction Weaning indices such as the rapid shallow breathing index (RSBI) have been used to identify mechanically ventilated patients who may be considered for spontaneous breathing trial (SBT). Traditionally, the RSBI is measured on a T-piece off any ventilatory support which requires a change in equipment and extra work for the respiratory therapist. Hypothesis A RSBI obtained after five minutes on low level of pressure support ventilation would predict the outcome of a 120-minute SBT. Methods We prospectively evaluated 25 mechanically ventilated medical ICU patients who were deemed ready to begin weaning by objective criteria. A SBT was initiated on pressure support ventilation (PSV) of 7 cm H2O. If the SBT was tolerated for 5 minutes, a RSBI was measured. The SBT was continued for 120 minutes unless the patient exhibited clinical signs of poor tolerance (by predefined criteria). Patients who failed the trial were returned to their previous ventilatory mode. Those who successfully finished the trial were extubated after remeasuring the RSBI. Successful extubation was defined when reintubation was not required within 48 hours. Results 32 weaning trials were evaluated in 27 patients. 3 trials resulted in self-extubation and were excluded from analysis. 24 of the 29 trials successfully completed a 120-minute SBT, of which 22 were extubated. A RSBI at 5 minutes of < 75 had a sensitivity of 95.8%, a specificity of 60%, a positive predictive value of 92%, and a negative predictive value of 75% for accurately predicting the outcome of the 120-minute SBT. Of the 22 patients extubated, only 3 required reintubation within 48 hours. Conclusions The RSBI done after 5 minutes on low-level PSV is an accurate, rapid predictor of the outcome of a 120-minute SBT and a patients ability to tolerate extubation.