Current definitions of acute lung injury and the acute respiratory distress syndrome

Radiologic, Neurologic and Cardiopulmonary Aspects of Submersion Injury

Many indices and scores are used in critical care medicine to aid management and predict risk of mortality. We report 2 cases of submersion injury and discuss the usefulness and application of common respiratory and critical care indices. The respiratory indices help better understand the pulmonary pathophysiology and characterize the severity of lung injury and ventilation/perfusion mismatch. Severe lung injury resolved after ventilation support with appropriate positive end-expiratory pressure in both cases. The 6-year-old girl survived the near-fatal submersion injury intact despite grossly abnormal initial Glasgow Coma Scale (GCS) and high Pediatric Index of Mortality 2 scores, whereas the 5-year-old boy with grossly abnormal GCS and Pediatric Index of Mortality 2 scores died despite resolution of lung injury. These cases illustrate that resuscitation should be promptly instituted at the scene to ensure optimal outcome because initial pulmonology and neurology indices may not reliably predict mortality or intact survival. The GCS score was not initially designed for prognostication. Nevertheless, 2 serial GCS scores of 3, one performed at emergency department and one at the pediatric intensive care unit, were associated with nonsurvival in our second patient.

Chlamydial pneumonitis: a creepy neonatal disease

We present a case of neonatal chlamydial pneumonitis to illustrate that a high index of suspicion is necessary to make the diagnosis so that treatment can be promptly instituted. The child was afebrile and the only symptom was a cough. The respiratory equations are calculated to understand the respiratory physiology. There was no overt abnormality with ventilation, oxygenation, compliance, resistance, or ventilation-perfusion mismatch despite radiographic abnormality. The literature is searched to review if treatment with a systemic macrolide antibiotic is needed in an otherwise asymptomatic neonate with chlamydial pneumonitis.

Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award

OBJECTIVE

To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs).

DESIGN

An international, prospective, observational, cohort study conducted in May 2008.

SETTING

179 ICUs from 18 countries.

PATIENTS

2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours.

INTERVENTIONS

To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients.

MEASUREMENTS AND MAIN RESULTS

Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance.

CONCLUSIONS

There is variable performance with respect to critical care nutrition practices across the world.

Nutrition therapy for the critically ill surgical patient: we need to do better!

BACKGROUND

To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described.

METHODS

International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared.

RESULTS

A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy.

CONCLUSIONS

Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

BACKGROUND

The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines.

METHODS

The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e-mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice.

RESULTS

Twenty-six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes.

CONCLUSION

Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.

Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study

BACKGROUND

To evaluate the effect of enteral feeding protocols on key indicators of enteral nutrition in the critical care setting.

METHODS

International, prospective, observational, cohort studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) in 28 countries were combined for the purposes of this analysis. The study included 5497 consecutively enrolled, mechanically ventilated, adult patients who stayed in the ICU for at least 3 days. Sites recorded the presence or absence of a feeding protocol operational in their ICU. They provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. Sites that used a feeding protocol were compared with those that did not.

RESULTS

On average, protocolized sites used more enteral nutrition (EN) alone (70.4% of patients vs 63.6%, P = .0036), started EN earlier (41.2 hours from admission to ICU vs 57.1, P = .0003), and used more motility agents in patients with high gastric residual volumes (64.3% of patients vs 49.0%, P = .0028) compared with sites that did not use a feeding protocol. Overall nutritional adequacy (61.2% of patients' caloric requirements vs 51.7%, P = .0003) and adequacy from EN were higher in protocolized sites compared with nonprotocolized sites (45.4% of requirements vs 34.7%, P < .0001). EN adequacy remained significantly higher after adjustment for pertinent patient and ICU level baseline characteristics.

CONCLUSIONS

The presence of an enteral feeding protocol is associated with significant improvements in nutrition practice compared with sites that do not use such a protocol.

Exogenous surfactant therapy for ARDS

Regardless of the cause, a common pathophysiological feature of patients with acute respiratory distress syndrome is a dysfunction of the endogenous surfactant system. Although exogenous surfactant therapy has proven to be an effective treatment for neonatal respiratory distress syndrome, no similar current effective therapy exists for patients with acute respiratory distress syndrome. This is mainly due to the complexity of the lung injury that is involved with this disorder. Results from clinical trials, to date, have failed to show an improvement in patient survival after administration of exogenous surfactant; however, ongoing and future research efforts suggest that this therapy may eventually be feasible.

Survivors of acute respiratory distress syndrome: Relationship between pulmonary dysfunction and long-term health-related quality of life*

BACKGROUND

Patients who survive acute respiratory distress syndrome (ARDS) often report decreased general health-related quality of life (HRQOL) following hospital discharge. The extent to which this impairment is due to pulmonary or nonpulmonary causes is unclear. We describe the pattern of recovery of patients surviving ARDS to illuminate any relationships between lung spirometry values, pulmonary symptoms, and overall HRQOL.

METHODS

Seventy-three survivors of ARDS were enrolled in a 12-month follow-up study as part of a phase III randomized, multicenter trial. Patients were contacted at 3, 6, and 12 months after enrollment to complete generic and disease-specific HRQOL questionnaires and have lung spirometry tests performed.

RESULTS

For all domains of the Medical Outcomes Study Short Form-36 (SF-36) and the St. George's Respiratory Questionnaire (SGRQ) at all time intervals, survivors of ARDS had significantly lower scores than age- and sex-matched population values. Over the 12-month follow-up period, we observed significant improvements to the overall Physical Component Score, but the Mental Component Score of the SF-36 and the SGRQ scores were not statistically different. Physical performance measures suggested that by 12 months, 57% had not returned to "normal activity." At 12 months, lung spirometry tests demonstrated mild abnormalities that were stable over time (64% and 49% had <80% predicted forced expiratory volume in 1 sec [Fev1] and forced vital capacity [Fvc], respectively). At 12 months, the forced expiratory volume in 1 sec correlated strongly with the physical function domain of the SF-36 (correlation coefficient = 0.601; p < .01) and moderately with all domains of the SGRQ (correlation coefficient = -0.36, -50; p < .01 in all cases). In addition, there were several strong to moderate correlations between the various domains of the SF-36 and SGRQ.

CONCLUSIONS

Survivors of ARDS have considerable respiratory symptoms and reduced HRQOL that is still prevalent at 12 mos following onset of injury. There are significant correlations between lung spirometry, pulmonary symptoms, and overall HRQOL, thus suggesting the acute lung injury/ARDS is causally contributing to the observed long-term outcome.