"I had the feeling that I was trapped": a bedside qualitative study of cognitive and affective attitudes toward noninvasive ventilation in patients with acute respiratory failure.

BACKGROUND: Noninvasive ventilation (NIV) is the application of mechanical ventilation through a mask. It is used to treat certain forms of acute respiratory failure in intensive care units (ICU). NIV has clinical benefits but can be anxiogenic for the patients. This study aimed at describing cognitive and affective attitudes toward NIV among patients experiencing NIV for the first time in the context of an ICU stay. METHODS: Semi-structured interviews were conducted in 10 patients during their ICU stay and soon after their first NIV experience. None of the patients had ever received NIV previously. Evaluative assertion analysis and thematic analysis were used to investigate cognitive and affective attitudes toward NIV before, during, and after the first NIV experience, as well as patient attitudes toward caregivers and relatives. RESULTS: Before their first NIV session, the cognitive attitudes of the patients were generally positive. They became less so and more ambiguous during and after NIV, as the patients discovered the actual barriers associated with NIV. Affective attitudes during NIV were more negative than affective attitudes before and after NIV, with reports of dyspnea, anxiety, fear, claustrophobic feelings, and reactivation of past traumatic experiences. The patients had more positive attitudes toward the presence of a caregiver during NIV, compared to the presence of a family member. CONCLUSION: This study corroborates the possibly negative-or even traumatic-nature of the NIV experience, with emphasis on the role of affective attitudes. This is a rationale for evaluating the impact of NIV-targeted psychological interventions in ICU patients with acute respiratory failure.

Expiratory-synchronized sleep in a quadriplegic patient using inspiratory neck muscles to breathe.

In a patient with C3 quadriplegia causing complete diaphragm paralysis who developed inspiratory neck muscles (INM) hypertrophy to sustain ventilation, spontaneous breathing deeply altered sleep architecture, relegating sleep to the expiratory phase of the ventilatory cycle. A polysomnographic recording performed during mechanical ventilation (without INM activity), showed that sleep was abnormal but unaffected by the respiratory cycle. During spontaneous breathing, the polygraphic recordings showed expiratory microsleep episodes, with inspiratory arousals synchronous to bursts of INM activity. This case report illustrates the powerful adaptability of the respiratory and sleep control systems to maintain each vital function.

Omeprazole-induced intractable cough.

OBJECTIVE: To report a case of chronic, persistent cough induced by omeprazole therapy. CASE SUMMARY: A 42-year-old white woman presented with chronic, persistent cough after omeprazole initiation for treatment of postoperative heartburn. The cough was permanent, dry, and exhausting and worsened at night. Omeprazole therapy was continued for 4 months because the persistent cough was thought to be related to gastroesophageal reflux disease (GERD). However, no cause of persistent, chronic cough was identified. After omeprazole discontinuation, the cough resolved. DISCUSSION: The most common causes of chronic cough in nonsmokers of all ages are postnasal drip syndrome, asthma, and GERD. However, persistent cough without bronchospasm or other pulmonary involvement may occur as a drug adverse effect. According to the US omeprazole package insert, cough is observed as an adverse reaction in 1.1% of patients, although this has not been mentioned in international drug information sources or medical literature. A MEDLINE search (1966-June 2003) using the terms cough, drug related, adverse effects, and omeprazole failed to find any data. In our patient, there was a temporal relationship between cough and medication use, suggesting a causal relationship. An objective causality assessment revealed that the adverse drug reaction was probable. The mechanism is unclear. CONCLUSIONS: Chronic, persistent cough may occur as an adverse effect of omeprazole therapy. Clinicians must be aware of this adverse effect to avoid useless and costly tests.

Comparison of bedside measurement of cardiac output with the thermodilution method and the Fick method in mechanically ventilated patients.

INTRODUCTION: Bedside cardiac output determination is a common preoccupation in the critically ill. All available methods have drawbacks. We wished to re-examine the agreement between cardiac output determined using the thermodilution method (QTTHERM) and cardiac output determined using the metabolic (Fick) method (QTFICK) in patients with extremely severe states, all the more so in the context of changing practices in the management of patients. Indeed, the interchangeability of the methods is a clinically relevant question; for instance, in view of the debate about the risk-benefit balance of right heart catheterization. PATIENTS AND METHODS: Eighteen mechanically ventilated passive patients with a right heart catheter in place were studied (six women, 12 men; age, 39-84 years; simplified acute physiology scoreII, 39-111). QTTHERM was obtained using a standard procedure. QTFICK was measured from oxygen consumption, carbon dioxide production, and arterial and mixed venous oxygen contents. Forty-nine steady-state pairs of measurements were performed. The data were normalized for repeated measurements, and were tested for correlation and agreement. RESULTS: The QTFICK value was 5.2 +/- 2.0 l/min whereas that of QTTHERM was 5.8 +/- 1.9 l/min (R = 0.840, P < 0.0001; mean difference, -0.7 l/min; lower limit of agreement, -2.8 l/min; upper limit of agreement, 1.5 l/min). The agreement was excellent between the two techniques at QTTHERM values <5 l/min but became too loose for clinical interchangeability above this value. Tricuspid regurgitation did not influence the results. DISCUSSION AND CONCLUSIONS: No gold standard is established to measure cardiac output in critically ill patients. The thermodilution method has known limitations that can lead to inaccuracies. The metabolic method also has potential pitfalls in this context, particularly if there is increased oxygen consumption within the lungs. The concordance between the two methods for low cardiac output values suggests that they can both be relied upon for clinical decision making in this context. Conversely, a high cardiac output value is more difficult to rely on in absolute terms.