Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning.

BACKGROUND: Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients' characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions. RESULTS: Eighty tracheostomized patients were included (28.8% women, 60 [52-71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10-20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07-1.32] and 1.04 [1.01-1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09-1.36] and 1.04 [1.00-1.09], p < 0.001 and p = 0.046). CONCLUSIONS: Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning.

[Classic ventilatory modes for invasive mechanical ventilation]. / Modes ventilatoires de base en ventilation mécanique invasive.

Invasive mechanical ventilation is part of the daily practice of the intensivist and anesthetist. The comprehensive knowledge of ventilatory modes is mandatory for managing the ventilated patients. The objective of this article is to explain the characteristics of the barometric and volumetric modes and the differences between controlled, assist-controlled, and assisted ventilation. The most common modes (volume and pressure assist-control, dual modes and pressure support) are described in detail. Parameters that must be set and those that must be monitored in each mode are also described. Finally, suggestions for initial settings are provided in order to offer the reader unfamiliar with mechanical ventilation a practical decision-making aid.

La ventilation mécanique invasive est un outil indispensable à la pratique de l'intensiviste et de l'anesthésiste. La connaissance des modes ventilatoires est nécessaire pour la prise en charge des patients ventilés. L'objectif de cet article est, d'une part, de distinguer les caractéristiques des modes barométriques et volumétriques, et de comprendre les différences entre les modes contrôlé, assisté-contrôlé et assisté et, d'autre part, de distinguer les paramètres qui doivent être réglés de ceux qui doivent être monitorés. Les modes les plus utilisés (volume contrôlé, pression contrôlée, modes mixtes et aide inspiratoire) font l'objet d'une description détaillée. Des suggestions de réglages initiaux sont proposées pour ces modes afin d'offrir au lecteur peu familier avec la ventilation mécanique une aide décisionnelle pratique.

[Monitoring respiratory mechanics in ventilated patients: a bedside approach]. / Monitorage de la mécanique respiratoire chez le patient ventilé : comment procéder au lit du malade.

In clinical practice, the term respiratory mechanics usually refers to the concept of compliance and resistance of the respiratory system. In ventilated patients, measurements of compliance and resistance can be performed at the bedside using the ventilator (end- inspiratory and end-expiratory occlusions). Those measurements allow caregivers to monitor pulmonary disorders and evaluate treatment effectiveness. In case of sudden change in compliance or resistance, the variation of flow and pressure curves displayed on the ventilator screen helps to narrow down the differential diagnosis. This article defines what are compliance and resistance and how to calculate and use them at the bedside.

Le terme « mécanique respiratoire ¼ se rapporte souvent, en pratique, aux concepts de compliance et résistance du système respiratoire. Chez un patient ventilé, les mesures de compliance et de résistance s'effectuent à l'aide du ventilateur (occlusion télé-inspiratoire et télé-expiratoire). Ces mesures permettent de suivre l'évolution d'une atteinte pulmonaire ou l'efficacité d'un traitement administré. En cas de changement brusque de compliance ou de résistance, l'analyse des variations des courbes affichées sur l'écran du ventilateur permet d'élaborer un diagnostic différentiel rapidement. Cet article de synthèse décrit les concepts de compliance et résistance du système respiratoire, la façon de les calculer et de les utiliser au lit du malade.