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Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
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Kalchiem-Dekel O, Hossain S, Gauran C, Beattie JA, Husta BC, Lee RP, Chawla M. An evolving role for endobronchial ultrasonography in the intensive care unit. J Thorac Dis 2021; 13:5183-5194. [PMID: 34527358 PMCID: PMC8411164 DOI: 10.21037/jtd-2019-ipicu-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.
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Affiliation(s)
- Or Kalchiem-Dekel
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Saamia Hossain
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cosmin Gauran
- Department of Anesthesia and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason A Beattie
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bryan C Husta
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert P Lee
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mohit Chawla
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Patolia S, Farhat R, Subramaniyam R. Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure. J Thorac Dis 2021; 13:5125-5134. [PMID: 34527353 PMCID: PMC8411155 DOI: 10.21037/jtd-19-3709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/09/2021] [Indexed: 01/18/2023]
Abstract
Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.
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Affiliation(s)
- Setu Patolia
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
| | - Rania Farhat
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
| | - Rajamurugan Subramaniyam
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
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Gáti N, Kassai T, Prokopp T, Vizi A, Hetthéssy J. Pediatric tracheal injuries: Report on 5 cases with special view on the role of bronchoscopy and management. Injury 2021; 52 Suppl 1:S63-S66. [PMID: 32067775 DOI: 10.1016/j.injury.2020.02.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of these case reports is to draw the attention to the difficulties of diagnosing trachea injuries in children, who are often part of a polytrauma scenario. MATERIALS A retrospective multicenter analysis of 5 cases were analysed. The age of the children was between 1 and 16 years old. Injury mechanism was blunt thoracic trauma, misintubation and shot injury. RESULTS Case No.1. a three-year-old child suffered a train accident. Resuscitation and decompression of the tension pneumothorax were performed. CT found a pneumomediastinum and bubbles along the trachea. Thoracolaparotomy was performed. Bronchoscopy could not rule out a tracheal injury. The child died of a cerebral edema. Case No. 2: a 13 month drowned and was resuscitated. A chest drain was inserted to treat the pneumothorax. CT revealed a pneumomediastinum, which was drained and a small tear of the trachea. Bronchoscopy was not preformed. Case No. 3: 9 year-old polytrauma patient was airlifted with bilateral mini thoracostomies and chest drains for pneumothorax. CT revealed bilateral pneumothorax and pneumomediastinum. The chest drains were repositioned oxygenation improved, but some ventilation difficulties remained. CT revealed pneumomediastinum and a tracheal injury. This was bridged by a tube, and the mediastinum drained. The ventilation difficulties were resolved. Case No. 4: an eight-year-old boy was shot on the neck. The region was explored surgically and the laceration of the trachea was sutured. Case No. 5: 12-year-old girl suffered blunt thoracic trauma. CT revealed bilateral pneumothorax and pneumomediastinum. Bilateral thoracic drainage was performed, some ventilation problems persisted. CT and fiberoscopy revealed a rupture of the trachea. Thoracotomy was performed and the laceration was closed. CONCLUSION Pneumomediastinum and persistent ventilation difficulties should raise suspicion of a tracheal injury in a typical clinical scenario. Bronchoscopy is recommended for early diagnosis, despite the possibility of misdiagnosis. In certain cases CT scan only and close observation may be considered.
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Affiliation(s)
- Nikolett Gáti
- Department of Pediatric Traumatology, Traumatology Center of Péterfy Hospital, Budapest, Hungary.
| | - Tamás Kassai
- Department of Pediatric Traumatology, Traumatology Center of Péterfy Hospital, Budapest, Hungary
| | | | - András Vizi
- Department of Pediatric Surgery, University of Szeged, Szeged, Hungary
| | - Judit Hetthéssy
- Department of Orthopedics Semmelweis University, Budapest, Hungary
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Boily-Daoust C, Plante A, Adam C, Fortin M. Performance and safety of diagnostic procedures in superior vena cava syndrome. ERJ Open Res 2021; 7:00392-2020. [PMID: 33532462 PMCID: PMC7836491 DOI: 10.1183/23120541.00392-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
Superior vena cava syndrome (SVCS) is an uncommon condition resulting from extrinsic compression or intraluminal blockade of the superior vena cava. The increased upper body venous pressure results in distended subcutaneous vessels and oedema of the head, neck and arms. SVCS can be a medical emergency if associated with laryngeal or cerebral oedema. The most common SVCS aetiologies are intrathoracic malignancies, accounting for 60 to 86% of cases [1–3]. Standard bronchoscopy and EBUS-TBNA have good diagnostic yield and are relatively safe procedures in the setting of SVCS. However, complications may arise from the underlying malignancy and its proximity to central vital structures.https://bit.ly/37HXFUY
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Affiliation(s)
- Catherine Boily-Daoust
- Dept of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Alexandre Plante
- Dept of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Cedrick Adam
- Dept of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Marc Fortin
- Dept of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Kleffmann J, Pahl R, Ferbert A, Roth C. Factors influencing intracranial pressure (ICP) during percutaneous tracheostomy. Clin Neurol Neurosurg 2020; 195:105869. [PMID: 32353664 DOI: 10.1016/j.clineuro.2020.105869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Percutaneous tracheostomy (PT) is common on ICUs. An increase of intracranial pressure (ICP) can be observed in patients with acute cerebral diseases. Factors determining ICP increase remain unclear. PATIENTS AND METHODS Data for all PTs were collected prospectively. ICP, cerebral perfusion pressure (CPP), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), and heart rate (HR) were monitored continuously every minute. Primary outcome parameter was an increase of ICP during PT (ICP > 20 mmHg). Influencing factors were evaluated by the means of logistic regression analysis: Body mass index (BMI), age, gender, physician performing the procedure (neurologist vs. neurosurgeon), duration of the procedure, underlying disease, duration of mechanical ventilation, and baseline ICP value before the procedure. RESULTS A total of 175 PTs were performed during the observation period between 2010 and 2013. Of these, 54 received ICP monitoring and were included into this study. Median initial ICP value was 10.4 mmHg and rose significantly to a median value of 18.4 mmHg (p < 0.05). In 21 patients (38,9%) an increase of median ICP above 20 mmHg was seen during at least one interval. Comparing patients with and without pathological ICP increase a significant difference between the two groups was only observed for patients with an increased baseline ICP above 15 mmHg. All other factors had no significant influence on the development of a pathological ICP peaks during PT. CONCLUSION Percutaneous tracheostomies in patients with cerebral injury leads to a significant increase of ICP during the procedure. Patients with a baseline ICP > 15 mmHg are at risk to develop harmful ICP crises.
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Affiliation(s)
- Jens Kleffmann
- Neurocenter Kassel, Marburger Str. 85, 34127 Kassel, Germany; Department of Neurosurgery, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
| | - Roman Pahl
- Institute of Medical Biometry and Epidemiology (IMBE), Philipps University Marburg, Bunsenstraße 3, 35037 Marburg, Germany
| | - Andreas Ferbert
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany; Department of Neurology, Philipps University Marburg, Baldingerstraße, 35037 Marburg, Germany.
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Horiguchi T, Yanagi S, Yatsushiro K, Tsubouchi H, Matsumoto N, Nakazato M. A case of impaired consciousness due to large cystic metastatic brain tumors from lung adenocarcinoma successfully controlled with Ommaya reservoir placement. Respir Med Case Rep 2020; 30:101069. [PMID: 32373458 PMCID: PMC7193317 DOI: 10.1016/j.rmcr.2020.101069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 11/22/2022] Open
Abstract
Large cystic brain metastases from lung cancer are rare but cause substantial central nervous system symptoms that often deprive patients of opportunities to receive anticancer therapy. There are no standard therapeutic strategies against this relentless condition. Here we report a patient with large cystic brain metastases from lung adenocarcinoma successfully controlled with Ommaya reservoir placement and subsequent gamma knife surgery (GKS). A 62-year-old Japanese man presented with left upper extremity paresis. Magnetic resonance imaging revealed large cystic masses in both cerebral hemispheres and multiple brain nodules. Computed tomography of the chest showed irregular nodular shadows in the lower lobe of the right lung with multiple swollen lymph nodes. His performance status (PS) and level of consciousness worsened rapidly. Thus, at that time, we could not perform bronchoscopy with the goal of establishing a pathological diagnosis. Intracystic placement of an Ommaya reservoir followed by GKS dramatically improved his PS and level of consciousness. We were subsequently able to perform bronchoscopy, which resulted in a diagnosis of lung adenocarcinoma with 100% positivity of programmed cell death-1 ligand-1 expression. The patient was started on a 3-week cycle of pembrolizumab. Substantial reduction in tumor size was observed after one course of pembrolizumab treatment. The patient had a partial remission. He has been still receiving pembrolizumab with long-term efficacy. In conclusion, our report suggests that aggressive Ommaya reservoir placement should be considered for large cystic metastatic brain tumors, even in patients with undiagnosed cancer, poor PS, and impaired consciousness.
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Affiliation(s)
- Takanori Horiguchi
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 889-1692, Japan
| | - Shigehisa Yanagi
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 889-1692, Japan
| | - Kazutaka Yatsushiro
- Department of Neurosurgery, Fujimoto General Hospital, Miyakonojo, Miyazaki, 885-0055, Japan
| | - Hironobu Tsubouchi
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 889-1692, Japan
| | - Nobuhiro Matsumoto
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masamitsu Nakazato
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 889-1692, Japan
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8
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Pantazopoulos I, Kokkoris S, Routsi C. Tooth Aspiration in a Patient with Traumatic Brain Injury. Turk Thorac J 2019; 20:262-264. [PMID: 31584389 DOI: 10.5152/turkthoracj.2019.180193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/14/2019] [Indexed: 11/22/2022]
Abstract
Tooth aspiration is a rare issue in the course of patients with trauma and may remain undiagnosed for a long period, resulting in delayed complications, such as atelectasis and recurrent infections. Flexible bronchoscopy is considered the preferred primary procedure for the management of airway foreign bodies in adults. However, it may cause intracranial hypertension in trauma patients with concomitant head injuries. We herein report a case of a patient with traumatic brain injury who underwent tooth aspiration using flexible bronchoscopy, with continuous monitoring of intracranial pressure (ICP). The importance of a thorough review of radiographs and chest computed tomography for foreign body aspiration in trauma patients was highlighted, particularly in a maxillofacial trauma, as tooth aspiration may remain undiagnosed for extended periods. Moreover, the difficulty in maintaining the ICP within normal limits during bronchoscopy in patients with traumatic brain injury was reinstated, and the need for continuous monitoring of the cerebral hemodynamics and harmonization was emphasized, with recommendations for bronchoscopy via an endotracheal tube.
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Affiliation(s)
- Ioannis Pantazopoulos
- First Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Stelios Kokkoris
- First Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Christina Routsi
- First Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
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9
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Pulmonary Consult: Management of Severe Hypoxia in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Mohan A, Madan K, Hadda V, Tiwari P, Mittal S, Guleria R, Khilnani GC, Luhadia SK, Solanki RN, Gupta KB, Swarnakar R, Gaur SN, Singhal P, Ayub II, Bansal S, Bista PR, Biswal SK, Dhungana A, Doddamani S, Dubey D, Garg A, Hussain T, Iyer H, Kavitha V, Kalai U, Kumar R, Mehta S, Nongpiur VN, Loganathan N, Sryma PB, Pangeni RP, Shrestha P, Singh J, Suri T, Agarwal S, Agarwal R, Aggarwal AN, Agrawal G, Arora SS, Thangakunam B, Behera D, Jayachandra, Chaudhry D, Chawla R, Chawla R, Chhajed P, Christopher DJ, Daga MK, Das RK, D'Souza G, Dhar R, Dhooria S, Ghoshal AG, Goel M, Gopal B, Goyal R, Gupta N, Jain NK, Jain N, Jindal A, Jindal SK, Kant S, Katiyar S, Katiyar SK, Koul PA, Kumar J, Kumar R, Lall A, Mehta R, Nath A, Pattabhiraman VR, Patel D, Prasad R, Samaria JK, Sehgal IS, Shah S, Sindhwani G, Singh S, Singh V, Singla R, Suri JC, Talwar D, Jayalakshmi TK, Rajagopal TP. Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations. Lung India 2019; 36:S37-S89. [PMID: 32445309 PMCID: PMC6681731 DOI: 10.4103/lungindia.lungindia_108_19] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.
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Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - GC Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Luhadia
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - RN Solanki
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - KB Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Swarnakar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SN Gaur
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pratibha Singhal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irfan Ismail Ayub
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Bansal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashu Ram Bista
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shiba Kalyan Biswal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashesh Dhungana
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Doddamani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dilip Dubey
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Avneet Garg
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tajamul Hussain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Venkatnarayan Kavitha
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Umasankar Kalai
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Swapnil Mehta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Noel Nongpiur
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - N Loganathan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - PB Sryma
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Prasad Pangeni
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prajowl Shrestha
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jugendra Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tejas Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandip Agarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Agarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanendra Agrawal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Suninder Singh Arora
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Balamugesh Thangakunam
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - D Behera
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jayachandra
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhry
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Chawla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Chawla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Chhajed
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Devasahayam J Christopher
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - MK Daga
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjan K Das
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - George D'Souza
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raja Dhar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sahajal Dhooria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aloke G Ghoshal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bharat Gopal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Goyal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - NK Jain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Jindal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Jindal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Surya Kant
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Katiyar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Katiyar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Parvaiz A Koul
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jaya Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raj Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Lall
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mehta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - VR Pattabhiraman
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dharmesh Patel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajendra Prasad
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - JK Samaria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shirish Shah
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Girish Sindhwani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sheetu Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Virendra Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rupak Singla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - JC Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Talwar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - TK Jayalakshmi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - TP Rajagopal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
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Küchler J, Tronnier F, Smith E, Gliemroth J, Tronnier VM, Ditz C. The Impact of Intrahospital Transports on Brain Tissue Metabolism in Patients with Acute Brain Injury. Neurocrit Care 2019; 30:216-223. [PMID: 30203385 DOI: 10.1007/s12028-018-0604-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with severe acute brain injury (ABI) often require intrahospital transports (IHTs) for repeated computed tomography (CT) scans. IHTs are associated with serious adverse events (AE) that might pose a risk for secondary brain injury. The goal of this study was to assess IHT-related alterations of cerebral metabolism in ABI patients. METHODS We included mechanically ventilated patients with ABI who had continuous multimodality neuromonitoring during an 8-h period before and after routine IHT. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PtiO2) as well as cerebral and subcutaneous microdialysis parameters (lactate, pyruvate, glycerol, and glutamate) were recorded. Values were compared between an 8-h period before (pre-IHT) and after (post-IHT) the IHT. RESULTS A total of 23 IHT for head CT scans in 18 patients were analyzed. Traumatic brain injury (n = 7) was the leading cause of ABI, followed by subarachnoid hemorrhage (n = 6) and intracerebral hemorrhage (n = 5). The analyzed microdialysis parameters in the brain tissue as in the subcutaneous tissue did not show significant changes between the pre-IHT and post-IHT period. In addition, we observed no significant increase in ICP or decrease in CPP and PtiO2 in the 8-h period after IHT. CONCLUSIONS While the occurrence of AE during IHT is a known risk factor for ABI patients, our results demonstrate that IHTs do not alter the brain tissue chemistry in a significant manner. This fact may help assess the risk for routine IHT more accurately.
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Affiliation(s)
- Jan Küchler
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Franziska Tronnier
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Volker M Tronnier
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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12
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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Song J, Xuan L, Wu W, Zhu D, Zheng Y. Comparison of Percutaneous Dilatational Tracheostomy Guided by Ultrasound and Bronchoscopy in Critically Ill Obese Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1061-1069. [PMID: 29048709 DOI: 10.1002/jum.14448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/13/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES This study aimed to compare the efficacy and safety of percutaneous dilatational tracheostomy (PDT) with ultrasound (US) or bronchoscopic guidance for critically ill patients, notably obese patients. METHODS This work was a retrospective study. The study included mechanically ventilated patients who underwent PDT from August 2013 to July 2015 in the Department of Critical Care Medicine of Zhongshan Hospital. The patients were classified according to the different guidance methods during tracheotomy and their body mass index in the following 4 groups: normal bronchoscopy group, normal US group, obese bronchoscopy group, and obese US group. The parameters, including operation time, number of punctures, intraoperative and postoperative complications, duration of the intensive care unit stay, hospitalization time, and mortality, were recorded and compared between groups. RESULTS Compared with the obese bronchoscopy group, the obese US group had a significantly shorter PDT operation time (mean ± SD, 12.8 ± 4.8 versus 16.2 ± 4.4 minutes; P = .026), fewer punctures (P = .011), and a lesser amount of intraoperative hemorrhage (12.1 ± 4.6 versus 16.8 ± 4.3 mL; P = .009). There were no significant differences in these parameters between the normal US and normal bronchoscopy groups. CONCLUSIONS Ultrasound-guided PDT significantly reduced the number of punctures and the operation time compared with bronchoscopy-guided PDT, and it decreased intraoperative hemorrhage in critically ill obese patients. Percutaneous dilatational tracheostomy with US guidance was a faster, safer, and more accurate method of airway management.
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Affiliation(s)
- Jieqiong Song
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lizhen Xuan
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Wu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Duming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yijun Zheng
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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14
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Kheir F, Sierra-Ruiz M, Majid A. Safety of Flexible Bronchoscopy. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Review of Continuous Infusion Neuromuscular Blocking Agents in the Adult Intensive Care Unit. Crit Care Nurs Q 2017; 40:323-343. [PMID: 28834856 DOI: 10.1097/cnq.0000000000000171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of continuous infusion neuromuscular blocking agents remains controversial. The clinical benefit of these medications may be overshadowed by concerns of propagating intensive care unit-acquired weakness, which may prolong mechanical ventilation and impair the inability to assess neurologic function or pain. Despite these risks, the use of neuromuscular blocking agents in the intensive care unit is indicated in numerous clinical situations. Understanding pharmacologic nuances and clinical roles of these agents will aid in facilitating safe use in a variety of acute disease processes. This article provides clinicians with information regarding pharmacologic differences, indication for use, adverse effects, recommended doses, ancillary care, and monitoring among agents used for continuous neuromuscular blockade.
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Bochicchio GV, Bochicchio K, Nehman S, Casey C, Andrews P, Scalea TM. Tolerance and Efficacy of Enteral Nutrition in Traumatic Brain–Injured Patients Induced Into Barbiturate Coma. JPEN J Parenter Enteral Nutr 2017; 30:503-6. [PMID: 17047175 DOI: 10.1177/0148607106030006503] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
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Affiliation(s)
- Grant V Bochicchio
- R. Adams Cowley Shock Trauma Center, Division of Clinical and Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Abstract
Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.
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Abstract
Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient’s clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.
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Affiliation(s)
- Kimberly A Davis
- Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, Loyola University Medical Center, Maywood, IL, USA.
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Stahl DL, Richard KM, Papadimos TJ. Complications of bronchoscopy: A concise synopsis. Int J Crit Illn Inj Sci 2015; 5:189-95. [PMID: 26557489 PMCID: PMC4613418 DOI: 10.4103/2229-5151.164995] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Flexible and rigid bronchoscopes are used in diagnosis, therapeutics, and palliation. While their use is widespread, effective, and generally safe; there are numerous potential complications that can occur. Mechanical complications of bronchoscopy are primarily related to airway manipulations or bleeding. Systemic complications arise from the procedure itself, medication administration (primarily sedation), or patient comorbidities. Attributable mortality rates remain low at < 0.1% for fiberoptic and rigid bronchoscopy. Here we review the complications (classified as mechanical or systemic) of both rigid and flexible bronchoscopy in hope of making practitioners who are operators of these tools, and those who consult others for interventions, aware of potential problems, and pitfalls in order to enhance patient safety and comfort.
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Affiliation(s)
- David L Stahl
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Kathleen M Richard
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio, USA
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Grosu HB, Morice RC, Sarkiss M, Bashoura L, Eapen GA, Jimenez CA, Faiz S, Lazarus DR, Casal RF, Ost DE. Safety of flexible bronchoscopy, rigid bronchoscopy, and endobronchial ultrasound-guided transbronchial needle aspiration in patients with malignant space-occupying brain lesions. Chest 2015; 147:1621-1628. [PMID: 25393333 DOI: 10.1378/chest.14-1704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Bronchoscopy in patients with space-occupying brain lesions is anecdotally felt to carry a high risk of neurologic complications. METHODS We conducted a retrospective cohort study of patients with evidence of a malignant, space-occupying brain lesion who were referred for flexible or rigid bronchoscopy or endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The primary outcome of interest was the incidence of neurologic complications following the procedures in these patients. RESULTS Of the 103 enrolled patients, flexible bronchoscopy was performed in 41, rigid bronchoscopy in 12, and EBUS-TBNA in 50. Among these patients, 41 (40%) had evidence suggestive of increased intracranial pressure on imaging. Among all study patients, none (95% CI, 0-0.035) had neurologic, procedure-specific, or sedation-specific complications, and the level of care was not escalated in any of these patients. CONCLUSIONS On the basis of our findings, we recommend that procedures such as flexible or rigid bronchoscopy or EBUS-TBNA in patients with malignant space-occupying brain lesions should be considered reasonably safe as long as neurologic findings are stable.
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center.
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Mona Sarkiss
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Saadia Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, Michael DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
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Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
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Sanfilippo F, Santonocito C, Veenith T, Astuto M, Maybauer MO. The Role of Neuromuscular Blockade in Patients with Traumatic Brain Injury: A Systematic Review. Neurocrit Care 2014; 22:325-34. [DOI: 10.1007/s12028-014-0061-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dinh VA, Farshidpanah S, Lu S, Stokes P, Chrissian A, Shah H, Giri P, Hecht D, Nguyen HB. Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1407-1415. [PMID: 25063406 DOI: 10.7863/ultra.33.8.1407] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique. METHODS Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared. RESULTS Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups. CONCLUSIONS Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.
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Affiliation(s)
- Vi Am Dinh
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA.
| | - Siavash Farshidpanah
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Samantha Lu
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Phillip Stokes
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Ara Chrissian
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Harsh Shah
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Paresh Giri
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - David Hecht
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - H Bryant Nguyen
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
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Sheth KN. Neuroresuscitation—not to be taken lying down. J Crit Care 2013; 28:211-2. [DOI: 10.1016/j.jcrc.2012.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
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25
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Pulmonary complications during cardiac extracorporeal membrane oxygenation: Is bronchoscopy worth the bother? Pediatr Crit Care Med 2011; 12:474-5. [PMID: 21799312 DOI: 10.1097/pcc.0b013e3181fe345d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Tracheotomy is one of the most commonly performed procedures in critically ill patients. This article describes in particular the use of percutaneous dilatational tracheotomy. A brief history is included.
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Affiliation(s)
- Kia Sheykholeslami
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals/Case Medical Center/Ireland Cancer Center, Cleveland, OH 44106, USA
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Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009; 11:135-42. [PMID: 19644774 DOI: 10.1007/s12028-009-9255-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 07/21/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of the neurological "wake-up test" (NWT), defined as interruption of continuous propofol sedation and evaluation of the patient's level of consciousness, on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). METHODS A total of 127 NWT procedures in 21 severely brain-injured adult patients with either TBI (n = 12) or SAH (n = 9) were evaluated. ICP and CPP levels prior to, during and after the NWT procedure were recorded. RESULTS During the NWT, ICP increased from 13.4 +/- 6 mmHg at baseline to 22.7 +/- 12 (P < 0.05) and the CPP increased from 75.6 +/- 11 to 79.1 +/- 21 mmHg (P < 0.05) in TBI patients. Eight patients showed a reduced CPP during the NWT due to increased ICP. In SAH patients, ICP increased from 10.6 +/- 5 to 16.8 +/- 8 mmHg (P < 0.05) and the CPP increased from 76.9 +/- 13 to 84.6 +/- 15 mmHg (P < 0.05). CONCLUSION When continuous propofol sedation was interrupted and NWT was performed in severely brain-injured patients, the mean ICP and CPP levels were modestly increased. A subset of patients showed more pronounced changes. To date, the role of the NWT in the neurointensive care of TBI and SAH patients is unclear. Although the NWT is safe in the majority of patients and may provide useful clinical information about the patient's level of consciousness, alternate monitoring methods are suggested in patients showing marked ICP and/or CPP changes during NWT.
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Affiliation(s)
- Karin Skoglund
- Department of Neuroscience, Neurosurgery, Uppsala University Hospital, 751 85 Uppsala, Sweden
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28
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Awake fibreoptic intubation in neurosurgery. J Clin Neurosci 2009; 16:366-72. [DOI: 10.1016/j.jocn.2008.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 05/27/2008] [Accepted: 05/27/2008] [Indexed: 11/22/2022]
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29
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Neurologic injury and mechanical ventilation. Neurocrit Care 2008; 9:400-8. [PMID: 18696268 DOI: 10.1007/s12028-008-9130-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 07/16/2008] [Indexed: 10/21/2022]
Abstract
Mechanical ventilation in neurologically injured patients presents a number of unique challenges. Patients who are intubated due to a primary neurologic injury often experience respiratory phenomena secondary to that injury, including elevation of intracranial pressure (ICP) in response to mechanical ventilation and variations in respiratory patterns. These problems often require unique ventilator strategies that are designed to minimize the impact of the ventilator on ICP and brain oxygenation. Balancing the need to maintain brain oxygenation and control of ICP can be complicated by the effects of ventilator management on ICP. We will examine the consequences of ventilator management as they relate to parameters that affect ICP and brain oxygenation in patients who have neurologic injury.
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Pelosi P, Barassi A, Severgnini P, Gomiero B, Finazzi S, Merlini G, d'Eril GM, Chiaranda M, Niederman MS. Prognostic Role of Clinical and Laboratory Criteria To Identify Early Ventilator-Associated Pneumonia in Brain Injury*. Chest 2008; 134:101-8. [DOI: 10.1378/chest.07-2546] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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31
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[Diagnostic flexible bronchoscopy. Recommendations of the Endoscopy Working Group of the French Society of Pulmonary Medicine]. Rev Mal Respir 2008; 24:1363-92. [PMID: 18216755 DOI: 10.1016/s0761-8425(07)78513-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification. Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.
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Jelic S, Cunningham JA, Factor P. Clinical review: airway hygiene in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:209. [PMID: 18423061 PMCID: PMC2447567 DOI: 10.1186/cc6830] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Maintenance of airway secretion clearance, or airway hygiene, is important for the preservation of airway patency and the prevention of respiratory tract infection. Impaired airway clearance often prompts admission to the intensive care unit (ICU) and can be a cause and/or contributor to acute respiratory failure. Physical methods to augment airway clearance are often used in the ICU but few are substantiated by clinical data. This review focuses on the impact of oral hygiene, tracheal suctioning, bronchoscopy, mucus-controlling agents, and kinetic therapy on the incidence of hospital-acquired respiratory infections, length of stay in the hospital and the ICU, and mortality in critically ill patients. Available data are distilled into recommendations for the maintenance of airway hygiene in ICU patients.
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Affiliation(s)
- Sanja Jelic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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Abstract
Ultrasound imaging of the upper airway in critically ill patients offers a number of attractive advantages compared with competitive imaging techniques or endoscopy. It is widely available, portable, repeatable, relatively inexpensive, pain-free, and safe. In this review article, I describe ultrasonographic anatomy of the upper respiratory organs and present the main potential applications of ultrasonography in airway management. The role of ultrasound in endotracheal tube placement, including preintubation assessment, verification of tube position, double-lumen intubation, and extubation outcome, are explained. Also, ultrasound-guided percutaneous tracheostomy, the role of ultrasound in using the laryngeal mask airway, and upper airway anesthesia are described.
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Affiliation(s)
- Alan Sustić
- Department of Anesthesiology, University Hospital Rijeka, Rijeka, Croatia.
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Zygun DA, Zuege DJ, Boiteau PJE, Laupland KB, Henderson EA, Kortbeek JB, Doig CJ. Ventilator-associated pneumonia in severe traumatic brain injury. Neurocrit Care 2007; 5:108-14. [PMID: 17099256 DOI: 10.1385/ncc:5:2:108] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pneumonia is an important cause of morbidity following severe traumatic brain injury (TBI). However, previous studies have been limited by inclusion of specific patient subgroups or by selection bias. The primary objective of this study was to describe the incidence, risk factors for, and outcome of ventilator-associated pneumonia in an unselected population-based cohort of patients with severe TBI. An additional goal was to define the relationship of ventilator-associated pneumonia (VAP) with nonneurological organ dysfunction. METHODS A prospective, observational cohort study was performed at Foothills Medical Centre, the sole adult tertiary-care trauma center servicing southern Alberta. All patients with severe TBI requiring ventilation for more than 48 hours between May 1, 2000 and December 30, 2002 were included. RESULTS A total of 60 patients (45%) acquired VAP for an incidence density of 42.7/1000 ventilator days. Patients with polytrauma were at higher risk (risk ratio 1.7, 95% confidence interval, 0.9-3.1) for development of VAP than those with isolated head injury. Development of VAP was associated with a significantly greater degree of nonneurological organ system dysfunction. Although VAP was not associated with increased hospital mortality, patients who developed VAP had a longer duration of mechanical ventilation (15 versus 8 days, p < 0.0001), longer intensive care unit (17 versus 9 days, p < 0.0001) and hospital (60 versus 28 days, p = 0.003) lengths of stay, and more often required tracheostomy (35 versus 18%, p = 0.003). CONCLUSIONS VAP occurs frequently and is associated with significant morbidity in patients with severe TBI.
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Affiliation(s)
- David A Zygun
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
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35
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Abstract
Patients with acute brain injury are a distinct group within the ICU who may develop non-neurologic organ dysfunction in the absence of systemic injury or infection. This dysfunction may arise directly as a result of the brain injury or indirectly with complications of brain-specific therapies. This article reviews the current literature with respect to the incidence of organ dysfunction or failure and its association with outcome in patients with acute brain injury. Organ system-specific etiologic considerations and management are discussed.
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Affiliation(s)
- Luc Berthiaume
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Sustić A, Zupan Z, Antoncić I. Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient. J Clin Anesth 2004; 16:121-3. [PMID: 15110374 DOI: 10.1016/j.jclinane.2003.04.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2002] [Revised: 04/10/2003] [Accepted: 04/10/2003] [Indexed: 12/22/2022]
Abstract
Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method of long-term ventilation of critically ill patients in many intensive care units. However, it has certain contraindications that must be taken into account; for example, difficult anatomy and short, bull neck that are so often seen in morbidly obese persons. We present a case of a morbidly obese female patient in whom ultrasound-guided PDT was performed and in whom the airway was controlled by Laryngeal Mask Airway (LMA) during the procedure. Possible advantages of an ultrasonography-guided method and LMA control in morbidly obese patients also are discussed.
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Affiliation(s)
- Alan Sustić
- Department of Anesthesiology and ICU, University Hospital Rijeka, Rijeka, Croatia.
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Kreider ME, Lipson DA. Bronchoscopy for atelectasis in the ICU: a case report and review of the literature. Chest 2003; 124:344-50. [PMID: 12853543 DOI: 10.1378/chest.124.1.344] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Fiberoptic bronchoscopy has become a commonplace procedure in ICUs. Despite the fact that one of the most common indications for bronchoscopy is the presence of retained secretions and atelectasis, there is little research dedicated to its safety and utility in this clinical situation. This article presents a case of an intubated trauma victim who had undergone numerous bronchoscopic procedures, with varying degrees of success, for retained secretions and atelectasis. This review then seeks to answer the following three main questions regarding bronchoscopy in critically ill patients: (1) Is bronchoscopy effective in resolving atelectasis? (2) Is bronchoscopy superior to other means of resolving atelectasis? (3) Is bronchoscopy safe in critically ill patients? The patient was a 28-year-old man with no significant medical history who presented to the emergency department after his car was hit by a dump truck. He was found to have multiple leg fractures and a splenic rupture, and he was taken to the operating room for an exploratory laparotomy, splenectomy, and reduction of his fractures. He was then brought to the surgical ICU intubated, sedated, and receiving mechanical ventilation. Over the next 6 h, he developed progressive hypoxemia and diffuse, bilateral alveolar infiltrates on a chest radiograph (CXR). Four days postoperatively, a routine CXR revealed total atelectasis of his right upper lobe (RUL). Emergent bronchoscopy was performed, and a large mucus plug obscuring the RUL bronchus was removed. Follow-up CXR demonstrated resolution of the atelectasis. The next day, RUL atelectasis was again seen on his CXR. A repeat bronchoscopic examination and BAL failed to reveal any plug. A follow-up CXR showed continued atelectasis. Over the next week, the patient underwent daily bronchoscopy for atelectasis with variable degrees of improvement. Over the next 3 weeks, his pulmonary status improved until he was eventually extubated, and 1 month after hospital admission he was discharged to rehabilitation.
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Affiliation(s)
- Mary Elizabeth Kreider
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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Previgliano IJ, Ripoll PI, Chiappero G, Galíndez F, Germani L, González DH, Ferrari N, Hlavnicka A, Purvis C. Optimizing cerebral perfusion pressure during fiberoptic bronchoscopy in severe head injury: effect of hyperventilation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2003; 81:103-5. [PMID: 12168276 DOI: 10.1007/978-3-7091-6738-0_27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
The aim of this study was to evaluate if Hyperventilation (HV) could avoid the Intracranial Pressure (ICP) peak that occurs during Fiberoptic Bronchoscopy (FB) in severely head injured patients. A Cerebral Perfusion Pressure (CPP) > 75 mmHg was maintained in 34 patients, with a subgroup randomized to receive controlled HV during FB. Measurements were done before the procedure, during maximum ICP values and 30 minutes after FB. The HV group had minor ICP values after FB, without differences in CPP and ICP peak values.
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Affiliation(s)
- I J Previgliano
- ICU Hospital Fernández, Antártida Private Hospital, University del Salvador, Argentina
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Sustić A, Krstulović B, Eskinja N, Zelić M, Ledić D, Turina D. Surgical tracheostomy versus percutaneous dilational tracheostomy in patients with anterior cervical spine fixation: preliminary report. Spine (Phila Pa 1976) 2002; 27:1942-5; discussion 1945. [PMID: 12221364 DOI: 10.1097/00007632-200209010-00026] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized study. OBJECTIVES To compare the incidence of perioperative and early postoperative complications of surgical tracheostomy (ST) vs. ultrasound-guided percutaneous dilational tracheostomy (PDT) in patients with anterior cervical spine fixation (ACSF). SUMMARY OF BACKGROUND DATA The patients with ACSF after acute spinal cord injury often require tracheostomy. Surgical tracheostomy is burdened with relatively high incidence of peristomal infections, and, recently, ultrasound-guided PDT is proposed in patients with ACSF. METHODS Sixteen adult patients who underwent tracheostomy after acute spinal cord injury and ACSF were analyzed. The patients were randomly assigned to two groups: eight patients (six males; age range, 24-59 years) who underwent ST and eight patients (seven males; age range, 19-47 years) who underwent ultrasound-guided PDT with dilational forceps technique. The incidence of peri- and early postoperative complications was followed up, as well as the stoma infections and the duration of the procedure. RESULTS Not one patient from either group had any major perioperative complication of tracheostomy. In each group, there was one case of prolonged bleeding, which stopped spontaneously inside 24 hours. In two patients (25%) from the ST group, purulent infection of the stoma was verified during subsequent treatment at an intensive care unit. The average time of ST was 21 +/- 7 minutes; the average time of ultrasound-guided PDT was 8 +/- 6 minutes (P < 0.05). CONCLUSIONS Our preliminary data demonstrate that ultrasound-guided PDT as regards to complications is at least equally safe as ST; at the same time, it is much quicker method, probably with less late infections of the stoma, which could be an important advantage in patients with ACSF.
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Affiliation(s)
- Alan Sustić
- Department of Anesthesiology and Intensive Care Unit, University Hospital Rijeka, Croatia.
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Abstract
Worldwide, the increasing rates of microbial resistance represent a serious public health problem. Therefore, measures to prevent ventilator-associated pneumonia gain increasing importance. Because antimicrobial treatment in the ICU is a major source of microbial resistance, prevention should be understood not only as the sum of preventive measures but also as part of any management strategy. In this year of review, several important contributions have been made to a better understanding of the relative role of preventive measures. This is particularly true of noninvasive ventilation, continuous aspiration of subglottic secretions, and closed endotracheal suctioning. Management strategies for ventilator-assisted pneumonia remain highly controversial. Despite two decades of vigorous research, there is still no evidence that invasive bronchoscopic techniques should form part of a routine approach to suspected ventilator-assisted pneumonia. Moreover, an impact in terms of important outcome variables could not be consistently demonstrated. In the authors' view, the controversy regarding the relative validity of diagnostic tools should end, and the focus should shift to strategies that define low-risk patients with suspected ventilator-assisted pneumonia who can safely be treated by short-term monotherapy. Finally, several contributions have refined the established treatment regimen. Several new drugs for the treatment of ventilator-assisted pneumonia caused by Gram-positive multiresistant pathogens have been evaluated with promising results.
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Abstract
Neurologic complications in intensive care occur as the result of critical illness, intensive care therapies and procedures, or medical or surgical conditions; perioperatively; or because of underlying primary neurologic disease. These complications occur at greater frequency and are often unrecognized because critically ill patients are often intubated, sedated, and/or receiving neuromuscular blocking agents. Encephalopathy is the most common neurologic complication in the ICU and is usually multifactorial in origin. Sepsis is associated with the highest incidence of neurologic complications. Neurologic complications are associated with increased disability, longer hospital stay, and increased mortality. This review focuses on neurologic complications that are the result of critical illnesses and intensive care management.
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Affiliation(s)
- I Barlas
- Department of Surgery, Division of Critical Care Medicine, Mount Sinai Medical Center, City University of New York, New York, New York, USA
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