Respiratory Literature Summaries

OVERVIEW

  • ARDS
  • VAP
  • VTE
  • Miscellaneous

ARDS

VENTILATOR ACQUIRED PNEUMONIA

Drakulovic, M.B., et al (1999) “Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial” Lancet 3541851-1858

  • n = 86
  • single centre
  • supine VS semirecumbent -> study stopped at interim analysis c/o significant reduction in pneumonia in the semirecumbent -> risk factors for pneumonia = supine position + enteral nutrition

Fagon, J.Y., et al (2000) “Invasive and non-invasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial” Ann Intern Med 132:621-630

  • MCT
  • n = 413
  • inclusion criteria: ventilator-associated pneumonia
  • intervention = invasive management (direct bronchoscopy + lavage -> cultures and cessation of antibiotics if negative) VS non-invasive management (standard tracheal aspirates and empirical treatment) -> reduced mortality in invasive group (14 and 28 days) -> reduced antibiotic group in invasive group

VENOUS THROMBOEMBOLISM

Geerts, W.H., et al (2004) “Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy” Chest 126:338-400

  • detailed guidelines on the prevention of VTE
  • there is an absence of data in the critically ill

Konstantinides, S., et al – Management Strategies and Prognosis of Pulmonary Embolism – 3 Trial Investigators. (2002) “Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism” N Engl J Med 347:1143-1150

  • double blind RCT
  • n = 256
  • acute PE and PHT or RV dysfunction (not with hypotension)
  • heparin VS heparin + alteplase -> reduces clinical deterioration -> reduced need for interventions (CPR, emergency embolectomy, catheter thrombosis fragmentation) -> no fatal bleeding in lysis group -> did not change inhospital survival -> consider thrombolysis in sub-massive PE

The PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) – Dalteparin vs Unfractionated Heparin in Critically Ill Paitients – NEJM, March

  • MRCT
  • n = 3764 adults
  • primary end-point: proximal DVT assessment by twice weekly U/S

-> overall incidence proximal DVT incidence of 5.6% -> no difference in rates of proximal DVT between groups -> most DVT’s occur in ICU (not the ward) -> decreased PE rate in dalteparin group (NNT 100) -> no difference in bleeding -> no difference in HITS (trend to decrease with dalteparin)

MISCELLANEOUS

Naveanu, M. et al (2010) “Effect of oral beta-blocker on short and long term mortality in patients with acute respiratory failure: results from the Basel II-ICU study” Critical Care, 14:1-10

  • sub-study of an MRCT looking at BNP in the guidance of acute respiratory failure (BNP for Acute Shortness of Breath Evaluation II-ICU trial)
  • 7 ICU’s
  • Switzerland
  • n = 314
  • inclusion criteria: admission to ICU with respiratory failure
  • exclusion criteria: trauma, severe renal disease, previous BNP, > 12 hours of eligibility, sepsis, CPR, shock.
  • randomized to BNP measurement vs no BNP measurement

-> in hospital mortality 16% -> one year mortality 41% -> renal dysfunction, IHD, malignancy associated with increased mortality -> oral beta-blockers on admission or started during admission was associated with a lower risk of death (in hospital and at 1 year irrespective of whether respiratory failure cardiac or not) -> discontinuation of beta-blockers associated with higher mortality

Weaknesses

  • mechanism uncertain
  • post-hoc analysis
  • not generalisable to sepsis or shock -> shown to decrease mortality in COPD, heart failure, IHD, HT and now respiratory failure in ICU

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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