Current use and potential role of procalcitonin in the diagnostic work up and follow up of febrile neutropenia in hematological patients.

INTRODUCTION: Febrile neutropenia (FN) represents a life-threatening complication in hematological malignancies. Its etiology is most often due to infections even though FN of other origins, such as tumor-related fever and non-infectious inflammation, should rapidly be ruled out. Initially, C-reactive protein and, more recently, procalcitonin (PCT) have been proposed as useful biomarkers for differential diagnosis. PCT was shown to be a good biomarker of bacterial infections and their clinical outcomes. Definition of standard cut-offs and design of PCT-guided treatment protocols remain however to be defined. Areas covered: In this review, highlights on the current clinical use of PCT and its potential role as a diagnostic tool have been discussed by a panel of physicians from different areas of expertise. We provide current clinical evidence that PCT has been shown to be a reliable biomarker to differentiate fever of bacterial origin from other causes. Moreover, the Authors convened to a round-table to discuss their 'real-life experience' and offer their recommendations by a Delphi survey. Expert commentary: PCT has an important clinical role in FN. Issues such as the validation of a specific decision algorithm that includes PCT to monitor antibiotic choice and treatment duration will be addressed in prospective studies.

Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy.

PURPOSE: Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20-50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation. METHODS: Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission. RESULTS: At randomization, arterial-to-inspiratory O(2) ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10-0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27-0.78). CONCLUSIONS: This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission.

Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis.

OBJECTIVE: We evaluated the potential benefit of continuous positive airway pressure (CPAP) to prevent postoperative pulmonary complications (PPCs), atelectasis, pneumonia, and intubation in patients undergoing major abdominal surgery. SUMMARY BACKGROUND DATA: PPCs are common during the postoperative period and may be associated with a high morbidity rate. Efficacy of CPAP to prevent PPCs occurrence is controversial. METHODS: Medical literature databases were searched for randomized controlled trials examining the use of CPAP versus standard therapy in patients undergoing abdominal surgery. The meta-analysis estimated the pooled risk ratio and the number needed to treat to benefit (NNTB) for PPCs, atelectasis, and pneumonia. RESULTS: The meta-analysis was carried out over 9 randomized controlled trials. Overall, CPAP significantly reduced the risk of (1) PPCs (risk ratio, 0.66; 95% confidence interval [CI], 0.52-0.85) with a corresponding NNTB of 14.2 (95% CI, 9.9-32.4); (2) atelectasis (risk ratio, 0.75; 95% CI, 0.58-0.97; NNTB, 7.3; 95% CI, 4.4-64.5); (3) pneumonia (risk ratio, 0.33; 95% CI, 0.14-0.75; NNTB, 18.3; 95% CI, 14.4-48.8). In all cases the variation in risk ratio attributable to heterogeneity was negligible, although there was some evidence of publication bias. CONCLUSIONS: This systematic review suggests that CPAP decreases the risk of PPCs, atelectasis, and pneumonia and supports its clinical use in patients undergoing abdominal surgery.

Transtracheal open ventilation in acute respiratory failure secondary to severe chronic obstructive pulmonary disease exacerbation.

RATIONALE: Patients who fail noninvasive ventilation are generally intubated and are then subjected to complications of invasive mechanical ventilation. With transtracheal open ventilation, ventilator support is delivered through an uncuffed small bore minitracheostomy tube, which eliminates pooling of secretions above the cuff and thus reduces the risk of tracheobronchial microbial colonization. OBJECTIVE: To compare transtracheal open ventilation (treatment group) with conventional invasive ventilation (control group) in patients with exacerbation of chronic obstructive pulmonary disease who initially failed noninvasive ventilation. METHODS: Patients were randomized to receive trans-tracheal open ventilation (n=19) or conventional invasive ventilation (n=20). MEASUREMENTS AND MAIN RESULTS: There was no difference in arterial blood gases after 1 and 30 h between the two groups. Two patients receiving transtracheal open ventilation and 13 undergoing conventional ventilation had complications (p<0.0001). Compared with conventional ventilation, transtracheal open ventilation significantly decreased both the duration of mechanical ventilation (7.6+/-4.7 vs. 18.6+/-10.6 d, p<0.0001) and length of stay in the intensive care unit (10.2+/-4.5 vs. 21.3+/-9.7 d, p<0.0001). CONCLUSIONS: Transtracheal open ventilation was as effective as conventional ventilation in maintaining adequate gas exchange and reducing complications, duration of mechanical ventilation, and intensive care unit length of stay.

Patient-ventilator interaction during the triggering phase.

Partial patient-controlled mechanical support mode ventilators provide positive pressure assistance whenever a patient's inspiratory effort decreases pressure or flow in the ventilator circuit below the sensitivity set by clinicians; these modes minimize disuse atrophy of the respiratory muscles, can facilitate the weaning process, and usually require lower ventilator pressures. The capability of restoring gas exchange, unloading respiratory muscles, and relieving the patient's dyspnea with partial patient-controlled mechanical support modes depends on matching between the ventilator setting and the patient's ventilatory demand (ie, patient-ventilator interactions).

Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.

CONTEXT: Hypoxemia complicates the recovery of 30% to 50% of patients after abdominal surgery; endotracheal intubation and mechanical ventilation may be required in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive care unit and hospital stay. OBJECTIVE: To determine the effectiveness of continuous positive airway pressure compared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery. DESIGN AND SETTING: Randomized, controlled, unblinded study with concealed allocation conducted between June 2002 and November 2003 at 15 intensive care units of the Piedmont Intensive Care Units Network in Italy. PATIENTS: Consecutive patients who developed severe hypoxemia after major elective abdominal surgery. The trial was stopped for efficacy after 209 patients had been enrolled. INTERVENTIONS: Patients were randomly assigned to receive oxygen (n = 104) or oxygen plus continuous positive airway pressure (n = 105). MAIN OUTCOME MEASURES: The primary end point was incidence of endotracheal intubation; secondary end points were intensive care unit and hospital lengths of stay, incidence of pneumonia, infection and sepsis, and hospital mortality. RESULTS: Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). CONCLUSION: Continuous positive airway pressure may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery.

Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease: a feasibility study.

BACKGROUND: Noninvasive positive pressure ventilation (NPPV) with a facemask (FM) is effective in patients with acute exacerbation of their chronic obstructive pulmonary disease. Whether it is feasible to treat these patients with NPPV delivered by a helmet is not known. METHODS: Over a 4-month period, the authors studied 33 chronic obstructive pulmonary disease patients with acute exacerbation who were admitted to four intensive care units and treated with helmet NPPV. The patients were compared with 33 historical controls treated with FM NPPV, matched for simplified acute physiologic score (SAPS II), age, PaCO2, pH, and PaO2:fractional inspired oxygen tension. The primary endpoints were the feasibility of the technique, improvement of gas exchange, and need for intubation. RESULTS: The baseline characteristics of the two groups were similar. Ten patients in the helmet group and 14 in the FM group (P = 0.22) were intubated. In the helmet group, no patients were unable to tolerate NPPV, whereas five patients required intubation in the FM group (P = 0.047). After 1 h of treatment, both groups had a significant reduction of PaCO2 with improvement of pH; PaCO2 decreased less in the helmet group (P = 0.01). On discontinuing support, PaCO2 was higher (P = 0.002) and pH lower (P = 0.02) in the helmet group than in the control group. One patient in the helmet group, and 12 in the FM group, developed complications related to NPPV (P < 0.001). Length of intensive care unit stay, intensive care unit, and hospital mortality were similar in both groups. CONCLUSIONS: Helmet NPPV is feasible and can be used to treat chronic obstructive pulmonary disease patients with acute exacerbation, but it does not improve carbon dioxide elimination as efficiently as does FM NPPV.

Evaluation of patient skin breakdown and comfort with a new face mask for non-invasive ventilation: a multi-center study.

OBJECTIVE: To evaluate patient comfort, skin breakdown and eye irritation when comparing a prototype face mask (PM) and conventional face masks (CMs) during non-invasive ventilation. SETTING AND DESIGN: Eight centers (intensive or intermediate care units). Multicenter randomized study. POPULATIONS: Patients with acute respiratory failure of different etiologies. INTERVENTIONS: Patients were randomized to CMs or PM when ventilation was expected to last at least 12 consecutive hours a day for two consecutive days. Patient comfort, skin breakdown and eye irritation, assessed by means of standardized scoring systems, were measured after 24 and 48 h and before discontinuing ventilation. RESULTS: Hundred ninety-four patients were randomized. Forty-seven patients were finally enrolled: PM (24) and CMs (23). Ventilator settings were similar in the two groups at the beginning of the treatment and after 24 and 48 h. Skin breakdown was significantly higher in the CMs group over the study period ( p<0.001). Patient comfort was higher in the PM group after 24 and 48 h ( p=0.008 and p<0.001, respectively). Eye irritation was absent in both groups after 24 h and did not differ significantly after 48 h (p=0.539). Before ventilation was discontinued skin breakdown and patient comfort were significantly higher in the CMs group, when compared to the PM group ( p<0.001 and p=0.003, respectively). Eye irritation was slightly higher in the PM versus CMs group ( p=0.21). The time on ventilation was not significantly different between the two groups ( p=0.830). CONCLUSION: The PM significantly reduced skin breakdown while improving patient comfort, compared to the CMs.