Many organizations are looking for ways to reduce the cost and improve the quality of open-heart surgery. Fletcher Allen Health Care in Burlington, Vermont used a total quality management approach to do just that. The result was a dramatic improvement in outcomes. Fletcher Allen won the 1994 USA Today Quality Cup for its efforts.

OBJECTIVE The hypothesis that traditionally defined preoperative risk factors predict prolonged mechanical ventilation after coronary artery bypass graft surgery (CABG) was tested in our cohort. The predictive power of these factors was quantified, and specific patient subsets destined for prolonged mechanical ventilation after CABG surgery were defined. DESIGN Five hundred thirteen consecutive patients undergoing CABG were prospectively evaluated. Preoperative pulmonary evaluation included clinical historic data, standard spirometry, and arterial blood gas. Preoperative cardiac parameters included clinical parameters and left ventricular function assessment. Nonthoracic organ (renal, endocrine, pancreas, liver) function was assessed. SETTING University-based, tertiary referral center. INTERVENTIONS None (observational only). OUTCOMES MEASURED Duration of mechanical ventilation, duration of surgical ICU stay, and mortality. RESULTS Multivariate regression analyses revealed that for the patient undergoing routine elective surgery and the patient undergoing urgent surgery, prolonged mechanical ventilation and death were rare events (8.3% and 2.0%, respectively). The combination of reduced left ventricular ejection fraction and the presence of selected preexisting comorbid conditions (clinical congestive heart failure, angina, current smoking, diabetes) served as modest risk factors for prolonged mechanical ventilation; their absence strongly predicted an uncomplicated postoperative respiratory course. No pulmonary diagnosis, mechanical lung function, or blood gas parameter substantially contributed to predicting adverse outcome. Classification and regression tree subgroup analysis refined specific factors important in specific subgroups. CONCLUSION With the exception of left ventricular ejection fraction, no preoperative factors emerge as good predictors across all subgroups. This series suggests that pulmonary diagnosis, lung mechanics, and blood gas parameters do not offer the clinician global rules in predicting postoperative respiratory outcome, nor should they be used as exclusion crteria for CABG surgery.

This report presents data obtained in the care of 830 patients requiring assisted ventilation. When these patients were divided into groups by the severity of their respiratory failure as defined by the duration of ventilatory assistance (greater than 48 hours, less than 48 hours) and level of positive end expiratory pressure (PEEP) required (greater than 5 cm HoH, less than 5 cm HoH), it was found that evidence of concurrent bacterial infection was present in the majority of patients with severe respiratory failure. This finding could not be explained by infection acquired after the onset of respiratory failure. In addition, this analysis demonstrated the important association of active pulmonary infection with the occurrence of barotrauma in these patients. Case analysis of patients subjected to extracorporeal membrane oxygenation has led to the suggestion that underlying sepsis in patients failing to respond to conventional ventilatory assistance similarly limits the usefulness of membrane oxygenator support.

Major blunt chest trauma is a multifaceted, complex problem with rising incidence, deficiencies in emergency care, inadequate comprehension of dynamics and of pathophysiology, inordinately delayed or missed diagnoses, controversies in and complications deriving from management. The major problem of flail chest is greatly complicated by accompanying lung contusion. Interference with the mechanical component of function result from flail, intrapleural collections, loss of ventilable lung tissue and parenchymal damage—disturbances in effective alveolar ventilation. Impairment of the many components of lung function result in abnormalities in V̇/Q̇ manifested by low Pao 2 and increased A-aDo 2 . Current thesis indicates the fundamental defect is physiologic shunting. Pathodynamics are poorly understood and have been inadequately studied. Most dissertations (including our own) are based on extrapolations of relatively unrelated experimental conditions, inductive hypothetical reasoning and biologic tampering with physical laws. In this context, it appears thoracic cage injury is due to direct impact force and its dissemination. Most intrathoracic injuries are the result of secondary phenomena generated either from the direct impact or the environment of the accident. Clinical perception stands as the sole sure way of rapid, accurate assessment of life-threatening components of thoracic injury and of patient progress during therapy. Radiology and laboratory tests are supplemental and confirmatory, except in special situations. Delayed or missed diagnoses are due to lack of, or faulty, perception. The singular laboratory aid is the Pao 2 and calculation of A-aDo 2 . Shock is not often due to a purely thoracic injury. Significant hypovolemia suggests a complicating nonthoracic problem, such as long bone or pelvic fracture or intra-abdominal catastrophe. Emergencies are relative, except those due to a crippled cardiopulmonary system which requires immediate restitution and stabilization. A step-by-step protocol executed with déliberate, programmed tension by team effort will insure the immediate saving of lives. A clear airway is achieved by prompt eradication of secretions and blood and by nasotracheal intubation . Tracheostomy in the hospital is an elective procedure and never performed as an emergency. Until the extent of chest pathology can be discerned, respirator support with 100% oxygen should be instituted and continued. Respirator management should be in the hands of skilled, experienced professionals, functioning as members of a team. The respirator does not reconstitute normal ventilation. A flail is stabilized and alveolar ventilation improved. Arterial blood gases and the estimated A-aDo 2 are the best guides for respirator and other technical adjustments. For patient adjustments, the best guide is clinical judgment, which in turn is sharpened by relentless pursuit and tenacity. Evacuation of air or blood or both by large tube thoracotomy is vital. External stabilization of the flail segment should be limited to on-the-site and in-transit operations. IPPV with the lungs as pneumatic splints is the preferred in-hospital procedure. Flails uncomplicated by lung contusion are uniformly controlled. Not all flails require respirator support. It is wise to institute IPPV, however, until the magnitude of the instability can be ascertained. Lung contusions are the problem, giving rise to the majority of complications, particularly pneumonia. If not arrested, progressively increasing O 2 concentrations are required over long periods of time. The spreading pneumonitis culminates in acute respiratory failure. This, coupled with prolonged O 2 therapy, may convert the lungs into a rubbery functionless mass. Relatively new problems related to gram-negative pneumonias and to the respirator have emerged. In a well-organized and run trauma service, lives may be saved only to be lost to acute respiratory failure and respirator generated complication—O 2 toxicity and lung rupture. Since these complications are iatrogenic, they can be prevented.