Background: Transpulmonary pressure (PL) manometry is used to assess pulmonary mechanics and guide lung protective mechanical ventilation (LPV). PL manometry is recommended to individualize LPV settings for patients with increased chest wall elastance and hypoxemia. Our primary aim was to determine if non-PL guided LPV settings, pulmonary mechanics, and oxygenation differ 1-day after receiving PL guided LPV among obese mechanically ventilated (MV) patients. Secondary endpoints: Ventilator-free days (VFD), ICU length of stay (LOS), and overall ICU mortality.. Methods: This was an IRB approved retrospective analysis of prospectively collected quality improvement data from MV adult obese patients. All patients were MV for a period prior to placement of an esophageal balloon catheter. Ventilator settings, pulmonary mechanics, and oxygenation were recorded on the initial day of PL measurement (D1, non-PL guided LPV). PL guided LPV targeted Inspiratory PL Results: 19 patients (63% male) with median age 49 (40-65) y, BMI 46.3 (36.6-55.9) kg/m2, and SOFA score 8 (6-11) were included in our sample. 13 (68%) patients received care in the medical ICU and 6 (32%) in our surgical/trauma ICU. PL measurement occurred 16 (9-21) h after initiating non-PL guided LPV in an effort to optimize ventilator settings. PL guided LPV resulted in higher PEEP [14 (14-20) vs 18 (17-25)], P Conclusions: PL guided LPV results in higher PEEP, lower FIO2, improved pulmonary mechanics, and greater oxygenation when compared to non-PL guided LPV MV settings in adult obese patients. Future studies should evaluate early PL guided LPV among obese pts and the effect on VFD, ICU LOS, and ICU mortality.

Background: The COVID-19 pandemic presented an array of challenges across healthcare, notably critical care staffing models. The potential for mechanical ventilation (MV) to be managed in part by practitioners unaccustomed to doing so revealed the need for basic and applicable education. Detailed online modules and quick-reference document formats emerged to bridge knowledge gaps. A one-page primer for MV was developed and widely disseminated. Methods: A panel of experts composed of respiratory care clinicians, educators, and managers developed a bedside MV reference intended to aid clinicians who were assisting in the MV management of COVID-19 patients. Mean respiratory care experience amongst the panel was 22 years (11-31). The panel developed the MV reference based on evidence-based practice, consensus guidelines, and ventilator platform configurations. The MV reference summarized initial ventilator settings and assessment-based adjustments as well as recommended ARDS guidelines. A glossary of commonly used terms and modes of ventilation was also included. Results: The MV reference was distributed via social media (Twitter, Facebook, LinkedIn). According to available analytics, social media posts were viewed 46,745 times and the MV reference attachment was opened 2,815 times. It is unclear from available analytics how many times it was downloaded. The MV reference was also posted to the AARC’s clinical resource page, AARC Connect, and SCCM Connect. The AARC’s “Mechanical Ventilation for COVID-19 Video Series” webpage, on which the MV reference was posted, showed 34,501 site visits, though data relevant to downloads of the MV reference specifically was not available. Data relevant to views associated with AARC Connect or SCCM Respiratory Care Section as well as institutional utilization were unavailable. Our data is inconclusive and limited since we could not analyze which specific information was accessed or if our document was downloaded; nor did we intend to collect outcomes. Conclusions: Quick reference educational tools and just-in-time learning can be developed and disseminated rapidly in times of crisis. Attention to evidence-based practice and expert experience in the development of these tools ensures appropriate guidance. More research is needed to assess the effects these educational efforts have on outcomes.

INTRODUCTION:It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population.METHODS:The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min).RESULTS:Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P = .001) and use of bronchodilator therapy (81% vs 61%, P = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P = .03) and hospital days (12 vs 8 d, P = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P = .10) and faster time to intubation when HFNC failed (19 vs 9 h, P = .08).CONCLUSIONS:Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.

Lamb, Keith; Trump, Matthew; Oetting, Trevor; Jackson, Julie; Blake, David; Spilman, Sarah; Sahr, Sheryl

BACKGROUND:The non-rebreather mask (NRBM) is used for many applications and in many patient care scenarios in which hypoxemia and resultant hypoxia are a concern. The NRBM is a low-flow oxygen delivery system that is easily deployed and capable of delivering a relatively high fraction of inspired oxygen (FiO2).The potential for ineffective carbon dioxide (CO2) removal at low flow rates is a safety concern.OBJECTIVE:The authors hypothesized that the use of an OxyMask (Southmedic Inc, Canada) would mitigate these safety concerns while still delivering a relatively high FiO2.METHODS:Bench studies were performed in a third-party laboratory by qualified engineers (Piper Medical, USA). A Harvard Respirator Pump (Harvard Apparatus, USA), oxygen source, CO2 source and a mannequin head were used to simulate varying respiratory conditions. End tidal CO2 (EtCO2), FiO2, fraction of inspired CO2 and percent drop in CO2 in the first second of exhalation were measured at different mask flow rates and respiratory rates. There were two categories of flow rates: high-flow (15 L/min) and low-flow (2 L/min). In each flow group, the above parameters were measured using a tidal volume of 400 mL, inspiratory/expiratory ratio of 1:2, EtCO2 of 5% and a breathing frequency of 15, 20 or 24 breaths/min. Mask performance measurements were obtained and compared.CONCLUSION:The OxyMask outperformed the traditional NRBM in each tested category. There was a higher inspired oxygen level, lower inspired CO2 level, and more efficient CO2 clearance at each mask flow level and simulated patient minute volume. This was especially true during conditions in which there were very low mask flow rates.

SESSION TITLE: Mechanical Ventilation & Respiratory Failure II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: The purpose of this study was to evaluate compliance of utilizing appropriate tidal volumes and modes of ventilation in patients with respiratory failure. METHODS: This is a retrospective analysis of a before and after interventional performance improvement project. 400 intubated patients were studied. 200 patients were evaluated before intervention and 200 were evaluated after the intervention. Intervention consisted of education and resources provided to ICU staff. Primary outcomes measurements were adherence to ARDSnet low tidal volume guidelines including appropriate tidal volume selection and controlled ventilation (volume or pressure). All statistical analyses were performed with IBM SPSS Basic Statistics for Windows, version 20.0 (IBM Corp, 2011). All statistical tests were based on a 0.05 significance level. RESULTS: We collected service demographics, tidal volume sizes, modes of ventilation and oxygenation indices. Additionally, mortality was evaluated for each group and sub-group. All data were calculated and compared between phase one and phase two. Use of tidal volumes > 8ml/kg/pbw was (63%) phase one, (29%) phase two (p <.001), Tidal volumes ≥ 6ml and ≤ 8ml (34%) phase one, (63%) phase two (p <.001). The use of Pressure Regulated Volume Control (PRVC) was utilized in (77%) of patients phase one, and (18%) phase two (p <.001). Volume Controlled Ventilation was used in (5%) of patients phase one and (74%) Phase two (p <0.001). Acuity levels as they relate to respiratory failure were assigned by determining the number of patients that had a P/F ratio of ≤ 100. This was (4%) in phase one and (7%) in phase two (p 0.19) with mortality rates of (25%) and (64%) respectively (p < 0.05). CONCLUSIONS: Through organized educational efforts and surveillance of practice patterns our respiratory care department in conjunction with other practicing critical care clinicians were able to bring practice patterns into much closer proximity to the available published literature. The acuity level of our critical care census was almost double in the phase two patients, and despite this the mortality difference between each group did not reach statistical significance. This would seem to support that these efforts potentially effected outcomes in a positive way. This requires further investigation. CLINICAL IMPLICATIONS: Clinical implications include a much better compliance to accepted standards (already supported by the evidence) of mechanical ventilation practice patterns which in turn will improve patient outcomes. DISCLOSURE: The following authors have nothing to disclose: Keith Lamb, Trevor Oetting, Julie Jackson, Gregory Hicklin No Product/Research Disclosure Information

Rationale: Blood gas analysis is often used to assess acid–base, ventilation, and oxygenation status in critically ill patients. Although arterial blood gas (ABG) analysis remains the gold standard, venous blood gas (VBG) analysis has been shown to correlate with ABG analysis and has been proposed as a safer less invasive alternative to ABG analysis. Objective: The purpose of this study was to evaluate the correlation of VBG analysis plus pulse oximetry (SpO2) with ABG analysis. Methods: We performed a prospective cohort study of patients in the emergency department (ED) and intensive care unit (ICU) at a single academic tertiary referral center. Patients were eligible for enrollment if the treating physician ordered an ABG. Statistical analysis of VBG, SpO2, and ABG data was done using paired t test, Pearson χ2, and Pearson correlation. Main Results: There were 156 patients enrolled, and 129 patients completed the study. Of the patients completing the study, 53 (41.1%) were in the ED, 41 (31.8%) were in the medical ICU, and 35 (27.1%) were in the surgical ICU. The mean difference for pH between VBG and ABG was 0.03 (95% confidence interval: 0.03-0.04) with a Pearson correlation of 0.94. The mean difference for pCO2 between VBG and ABG was 4.8 mm Hg (95% confidence interval: 3.7-6.0 mm Hg) with a Pearson correlation of 0.93. The SpO2 correlated well with PaO2 (the partial pressure of oxygen in arterial blood) as predicted by the standard oxygen–hemoglobin dissociation curve. Conclusion: In this population of undifferentiated critically ill patients, pH and pCO2 on VBG analysis correlated with pH and pCO2 on ABG analysis. The SpO2 correlated well with pO2 on ABG analysis. The combination of VBG analysis plus SpO2 provided accurate information on acid–base, ventilation, and oxygenation status for undifferentiated critically ill patients in the ED and ICU.

OBJECTIVE:High-flow nasal cannula (HFNC) has been shown to reduce the need for mechanical ventilation (MV) and to decrease hospital and ICU days for patients with severe respiratory compromise. HFNC has not been evaluated in trauma patients, thus the goal of this study is to describe the use of HFNC in a chest-injured population.METHODS:A retrospective study examined trauma patients with moderate to severe thoracic injury admitted to the ICU at a tertiary hospital between March 2012 and August 2015. HFNC was delivered by the Fisher & Paykel Optiflow system. Primary outcomes were the need for intubation after HFNC for respiratory failure, length of hospitalization, and mortality.RESULTS:During the study period, 105 patients with blunt chest trauma were admitted to the ICU and received HFNC therapy. Eighteen percent received MV prior to HFNC. Overall, 69% of patients who received HFNC never received MV, and 92% of patients were discharged alive. The intubation rate for respiratory failure after HFNC was 18%. For patients who did not receive MV prior to HFNC, delay to first HFNC was correlated with increased hospital days (r s = 0.41, p = 0.001) and ICU days (r s = 0.41, p < 0.001).CONCLUSIONS:Study results suggest that HFNC is comparable with other methods of noninvasive ventilation and may be beneficial for patients with thoracic injury. Additional investigation is warranted to determine if early use of HFNC can deliver effective respiratory support and prevent intubation in this population.

BACKGROUND:Patients are at risk for respiratory complications after sustaining blunt chest trauma, yet contradictory evidence exists about the utility of prophylactic respiratory therapy to reduce respiratory complications in this population. This study assessed the effectiveness of a proactive respiratory protocol on an in-patient ward to identify trauma patients at risk for pulmonary complications, administer appropriate therapies, and prevent deterioration requiring transfer to the ICU.METHODS:Trauma patients received a respiratory therapy evaluation at the time of admission to a general in-patient ward at a Level 1 trauma center. If subjects met protocol inclusion criteria, they received prophylactic respiratory treatments, primarily MetaNeb therapy, Vest therapy, or EzPAP. Multiple phases were included to evaluate the effectiveness of the protocol, with 50 subjects in each phase: a pre-protocol phase before adoption of the protocol; phase 1, which was found to have low physician adherence and overly broad inclusion criteria; and phase 2, with improved adherence and narrower inclusion criteria. Study inclusion criteria mirror the protocol criteria from phase 2: ≥3 rib fractures; pulmonary contusion; exacerbation of COPD, asthma, or other lung disease; or age ≥65 y with expected immobility of ≥48 h.RESULTS:The respiratory protocol was associated with an elimination of unplanned admissions to the ICU. After controlling for injury severity and other important clinical factors, receiving the protocol significantly decreased hospital stay by approximately 1.5 d. More subjects were admitted from the emergency department directly to the ward, avoiding the ICU. Bronchodilator use also decreased, although the result did not reach statistical significance.CONCLUSIONS:Study results suggest that a preventive respiratory protocol had a beneficial effect on patient outcomes; receiving the protocol reduced hospital days and eliminated unplanned admission to the ICU.

BACKGROUND:Humidified, high-flow nasal cannula (HFNC) enables mucociliary clearance, accurate oxygen measurement, precise control of flow, and low-level positive airway pressure. There is sparse information concerning the timing of HFNC on patient outcomes such as incidence of adverse events during hospitalization, ICU stay, and post-ICU stay.METHODS:This is a retrospective analysis of a heterogeneous population of medical and trauma ICU patients who received HFNC therapy in a critical care setting. The study sample included 145 subjects who were admitted to the ICU and received HFNC therapy between March 2012 and February 2014. HFNC was delivered by the Fisher & Paykel Optiflow system.RESULTS:Of the 145 subjects who received HFNC, 35 (24.1%) received mechanical ventilation before HFNC, 21 (14.5%) received mechanical ventilation after HFNC, and 89 (61.3%) never received mechanical ventilation. Delay to first HFNC was moderately associated with unplanned ICU admission and was strongly correlated with the development of ventilator-associated pneumonia. Subjects with a greater length of time between ICU admission and first use of HFNC experienced significantly longer stays in the ICU and post-ICU periods, even after controlling for adverse events and mechanical ventilation.CONCLUSIONS:Study results provide preliminary evidence that early use of HFNC is beneficial in a medical and trauma ICU population, as it was associated with decreased ICU and post-ICU lengths of stay and reduced incidence of adverse events. This suggests that HFNC should be considered early in the ICU as first-line oxygen therapy.

Mechanical ventilation is an important and ever-evolving component of everyday critical care. Clinicians can struggle to keep up with current literature and descriptions of advancement in a way that they can apply these changes to their bedside patient care. This article serves as a review of important recent findings related to invasive mechanical ventilation and describes their relevance to bedside critical care.

SOCIETY OF CRITICAL CARE MEDICINE 32ND CRITICAL CARE CONGRESS SAN ANTONIO, TEXAS, USA JANUARY 28-FEBRUARY 2, 2003: ORAL/SANDWICH PRESENTATIONS: Poster Presentation: Clinical Science: Pulmonary Disease Mechanical Ventilation: PDF Only