Differential Perceptions of Noninvasive Ventilation in Intensive Care among Medical Caregivers, Patients, and Their Relatives: A Multicenter Prospective Study-The PARVENIR Study.

BACKGROUND: Noninvasive ventilation (NIV) requires a close "partnership" between a conscious patient and the patient's caregivers. Specific perceptions of NIV stakeholders and their impact have been poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers' willingness to administer NIV and patients' and relatives' anxiety in relation to NIV. METHODS: This is a prospective, multicenter questionnaire-based study. RESULTS: Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, [1 to 5] vs. 1 [1 to 5]; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session-related level of anxiety was observed in 37% of patients and 45% of relatives. "Dyspnea during NIV," "long NIV session," and "the need to have someone at the bedside" were identified as independent risk factors of high anxiety in patients. CONCLUSIONS: Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59).

Noninvasive mechanical ventilation in patients having declined tracheal intubation.

PURPOSE: Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order. METHODS: Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011. RESULTS: Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group. CONCLUSIONS: Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).

A modified Cockcroft-Gault formula taking into account the body surface area gives a more accurate estimation of the glomerular filtration rate.

We sought to validate the improvement by adjustment for body surface area (BSA) of the accuracy of the original Cockcroft-Gault equation to estimate glomerular filtration rate (GFR), in a prospective cross-sectional study of 269 European patients with chronic kidney disease (CKD). We compared 3 methods: original Cockcroft-Gault equation, modified Cockcroft-Gault formula adjusted for BSA and abbreviated Modification of Diet in Renal Disease (MDRD) equation, using inulin clearance. Statistical analyses comprised repeated-measures analysis of variance (ANOVA), determination of the Pearson coefficient of correlation and a Bland-Altman concordance study. The ability of the GFR estimates to properly categorize patients in K/DOQI stages of CKD was also examined. Inulin clearance differed significantly from the standard Cockcroft-Gault method (ANOVA, p<0.001) and the abbreviated MDRD method (ANOVA, p<0.001) but not from the BSA-modified Cockcroft-Gault formula. Inulin clearance correlated better with the BSA-modified Cockcroft-Gault formula (r=0.88) and abbreviated MDRD equation (r=0.87) than with the standard Cockcroft-Gault equation (r=0.82). In concordance studies, bias was far smaller with the BSA-modified Cockcroft-Gault formula (mean bias -1.75 ml/min), than with the standard Cockcroft-Gault equation (mean bias -4.72 ml/min). The bias of the abbreviated MDRD was larger (mean bias +6.24 ml/min). Only patients with CKD stage 1 were better categorized with the BSA-modified Cockcroft-Gault formula and with the standard Cockcroft-Gault estimate than with the abbreviated MDRD equation. We conclude that adjustment for body surface area improves accuracy of the original Cockcroft-Gault equation.

[Pneumothorax]. / Pneumothorax.

Spontaneous idiopathic pneumothorax occurs frequently in young tall subjects with smoking habits, and is usually of good prognosis. Secondary pneumothorax is a life-threatening complication of an underlying lung disease, such as acute pneumonia. Pneumocystis carinii pneumonitis or chronic obstructive pulmonary disease. Short-term therapeutic options oppose non-traumatic needle aspiration, with a success rate of more than 50%, versus thoracic drainage, with a recurrence rate exceeding 35%. The existing literature also indicates that video-assisted surgery leads to a much better long-term prognosis than the standard drainage procedure, with a long-term recurrence rate of less than 2%, for equivalent hospital stays and complication rates. The widely accepted recommendation that surgery should be proposed only at the first or second pneumothorax recurrence may be challenged in the next decade.