Description and microbiology of endotracheal tube biofilm in mechanically ventilated subjects.

BACKGROUND: A biofilm is found on the inner side of endotracheal tubes (ETT) in mechanically ventilated patients, but its features and role in pneumonia remain unclear. METHODS: This prospective, observational, monocentric study included critically ill ventilated subjects. Measurement of the ETT inner volume was first performed before extubation using the acoustic reflection method. After extubation, the biofilm was studied by means of optical and atomic force microscopy. Bacteriological analysis was then performed and compared with clinical documentation. RESULTS: Twenty-four subjects were included. Duration of intubation lasted from 2 to 79 d (mean ± SD: 11 ± 15 d). The mean percentage of ETT volume loss evaluated in situ (n = 21) was 7.1% and was not linked with the duration of intubation. Analyses with atomic force microscopy (n = 6) showed a full coverage of the inner part of the tube with biofilm, even after saline rinse. Its thickness ranged from 0.8 to 5 µm. Bacteriological cultures of the biofilm (n = 22) often showed the same bacteria as in tracheal secretions, especially for pathogenic organisms. Pseudomonas aeruginosa and Candida albicans were among the most frequent microorganisms. In subjects who had experienced a successfully treated episode of ventilator-associated pneumonia (n = 5), the responsible bacteria were still present in the biofilm. CONCLUSIONS: ETT biofilm is always present in intubated patients whatever the duration of intubation and appears quickly after intubation. Even after soft rinse, a small but measurable part of biofilm remains always present, and seems strongly adherent to the ETT lumen. It contains potentially pathogenic bacteria for the lung.

Decreasing the adverse effects of endotracheal suctioning during mechanical ventilation by changing practice.

BACKGROUND: Little is known about the incidence of and risk factors for adverse effects from endotracheal suctioning. We studied the incidence and risk factors, and evaluated the effect of suctioning practice guidelines. METHODS: During a 3-month period, in 79 mechanically ventilated subjects, we recorded the adverse effects in 4,506 suctioning procedures. Then practice guidelines were implemented, and 1 year later, during another 3-month period, in 68 subjects, we recorded the adverse effects in 4,994 suctioning procedures. RESULTS: In the first period, adverse effects occurred frequently: oxygen desaturation in 46.8% of subjects and 6.5% of suctionings, hemorrhagic secretions in 31.6% of subjects and 4% of suctionings, blood pressure change in 24.1% of subjects and 1.6% of suctionings, and heart rate change in 10.1% of subjects and 1.1% of suctionings. After guidelines implementation, all complications, both separately and all together, were reduced. The incidence of all complications together decreased from 59.5% to 42.6% of subjects, and from 12.4% to 4.9% of procedures (both P < .05). PEEP > 5 cm H2O was an independent risk factor for oxygen desaturation. Receiving > 6 suctionings per day was a risk factor for desaturation and hemorrhagic secretions. The use of guidelines was independently associated with fewer complications. CONCLUSIONS: Endotracheal suctioning frequently induces adverse effects. Technique, suctioning frequency, and higher PEEP are risk factors for complications. Their incidence can be reduced by the implementation of suctioning guidelines.

Protracted outbreak of multidrug-resistant Acinetobacter baumannii after intercontinental transfer of colonized patients.

OBJECTIVE: To describe the course and management of a protracted outbreak after intercontinental transfer of 2 patients colonized with multidrug-resistant Acinetobacter baumannii (MDRAB). DESIGN: An 18-month outbreak investigation. SETTING: An 860-bed university hospital in France. PATIENTS: Case patients (ie, carriers) were those colonized or infected with an MDRAB isolate. METHODS: During the epidemic period, all intensive care unit (ICU) patients and contacts of carriers who were transferred to wards were screened for MDRAB carriage. Contact precautions, environmental screening, and auditing of healthcare worker (HCW) practices were implemented; rooms were cleaned with hydrogen peroxide mist disinfection. One ICU, in which most of the cases occurred, was closed on 4 occasions for thorough cleaning and disinfection. RESULTS: The 2 index case patients were identified as 2 patients who carried the same MDRAB strain and who were admitted to the hospital after repatriation from Tahiti 5 months apart. During an 18-month period, a total of 84 secondary cases occurred. Reintroduction of MDRAB into the ICUs occurred from patients previously colonized or from healthcare personnel. Termination of the outbreak was only achieved when all carriers from wards or the ICU were cohorted to an isolation unit with dedicated healthcare personnel. CONCLUSIONS: Intercontinental transfer of carriers of MDRAB can result in extensive outbreaks and serious disruption of the hospital's organization. Transmission from carriers most likely occurred via the hands of HCWs, poor cleaning protocols, airborne spread, and contaminated water from sink traps. This protracted outbreak was controlled only after implementation of an extensive control program and eventual cohorting of all carriers in an isolation unit with dedicated healthcare personnel.

Short-term effects of humidification devices on respiratory pattern and arterial blood gases during noninvasive ventilation.

BACKGROUND: The impact of humidification devices on ventilatory and arterial blood gases parameters during noninvasive ventilation (NIV) remains controversial. The aim of the study was to compare the short-term impact of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) during NIV for either hypercapnic or hypoxemic acute respiratory failure. METHODS: Consecutive subjects receiving NIV were successively treated with HME and HH in randomized order for 30 min each. At the end of each period, arterial blood gases were measured and ventilatory parameters were recorded. RESULTS: Eighty-one subjects were enrolled, of whom 52 were hypercapnic (with or without acidosis) and 29 hypoxemic. Minute ventilation was greater with the HME, in comparison with the HH (15 [12-18] vs 12 [10-16] median [interquartile range], P < .001), while P(aCO(2)) was increased when using HME, indicating a dead space effect. This effect was observed in all subjects, but was more pronounced in hypercapnic subjects (P(aCO(2)) 62 ± 17 mm Hg with HME vs 57 ± 14 with HH, P < .001). In a subgroup of 19 subjects with respiratory acidosis, alveolar hypoventilation improved only with the HH. The amplitude of the dead space impact was a function of the degree of hypercapnia. CONCLUSIONS: Use of an HME decreased CO(2) elimination during NIV, despite increased minute ventilation, especially in hypercapnic subjects.

Do hypooncotic fluids for shock increase the risk of late-onset acute respiratory distress syndrome?

OBJECTIVE: In patients with shock, late-onset acute respiratory distress syndrome (ARDS) carries poor prognosis. Hypooncotic fluids may improve kidney function preservation, whereas hyperoncotic fluids may in theory decrease the risk of late-onset ARDS. Our objective was to determine whether predominant or exclusive use of crystalloids and/or hypooncotic colloids for shock resuscitation influenced the risk of late-onset ARDS. PARTICIPANT AND SETTINGS: International prospective cohort of consecutive adults who were free of ARDS on admission and who received fluid resuscitation for shock in 115 intensive care units (ICUs) during a 4-week period. MEASUREMENTS AND RESULTS: Severity scores, hemodynamic status, indication for fluids, risk factors for ARDS, plasma expander use, transfusions, and late-onset ARDS were recorded prospectively. Logistic regression models were tested to determine whether predominant or exclusive use of hypooncotic fluids was associated with higher incidence of late-onset ARDS. Of 905 patients, 81 [8.9%; 95% confidence interval (CI) 7.2-11.0] developed ARDS, with no difference between patients given only hypooncotic fluids (10.4%; 95% CI 7.6-13.7) and the other patients (7.7%; 95% CI 5.5-10.5; p = 0.16). Late-onset ARDS was significantly associated with sepsis [odds ratio (OR) 1.90; 95% CI 1.06-3.40], worse chest X-ray score at fluid initiation (1.55; 95% CI 1.27-1.91), positive fluid balance (1.06 per l; 95% CI 1.02-1.09), and greater transfusion volume (1.14 per l; 95% CI 1.01-1.29). The proportion of hypooncotic fluids in the plasma expander regimen was not associated with late-onset ARDS (1.01 per %; 95% CI 0.99-1.01). CONCLUSIONS: Based on this observational study, there is no evidence that in patients with shock the use of hypooncotic fluids increases the risk of late-onset ARDS. This finding needs to be confirmed.

Reassessment of intravenous antibiotic therapy using a reminder or direct counselling.

OBJECTIVES: Encouraging reassessment of intravenous antibiotic therapy at days 3-4 is an important step in the management of patients and may be done by delivering a questionnaire or through systematic infectious disease physician (IDP) advice to prescribers. PATIENTS AND METHODS: In this before-and-after study, prescriptions of 13 selected intravenous antibiotics from surgical or medical wards were screened from a computer-generated listing and prospectively included. Three strategies were compared over three consecutive 8 week periods: conventional management by the attending physician (control group); distribution of a questionnaire to the physician (questionnaire group); or distribution of the questionnaire followed by IDP advice (Q-IDP group). The primary outcome was the percentage of modifications of antibiotic therapy at day 4, including withdrawal of therapy, de-escalation, oral switch or reducing the planned duration of therapy. RESULTS: Overall, 402 prescriptions were included. At day 4, 48.9% and 54.5% of prescriptions were modified in the control and questionnaire groups, respectively (P = 0.35). In contrast, more prescriptions (66.2%) were modified in the Q-IDP group as compared with the control group (P = 0.004). Stopping therapy in the absence of apparent bacterial infection occurred significantly more often in the Q-IDP group than in the control (P < 0.0001) or questionnaire groups (P = 0.002). CONCLUSIONS: This study shows a modest impact of only distributing a questionnaire aimed at reminding physicians to reassess therapy, whereas systematic IDP intervention improves the modification rate.

Impact of a computer-generated alert system prompting review of antibiotic use in hospitals.

OBJECTIVES: The aim of this study was to measure the impact on antibiotic use of a computer-generated alert prompting post-prescription review and direct counselling in hospital wards. METHODS: A computer-generated alert on new prescriptions of 15 antibiotics was reviewed weekly by an infectious disease physician for 41 weeks. During the first 6 months of the study, criteria selected for potential intervention were: (i) a planned duration of treatment of > or =10 days; (ii) discordance between the spectrum of the prescribed antibiotic and available microbiological results; or (iii) prescriptions of broad-spectrum beta-lactams, fluoroquinolones, glycopeptides or linezolid. During the following 5 months, the alert was restricted to any prescription of the 15 antibiotics in the 9 wards where overall antibiotic use had not decreased in the past year. RESULTS: We analysed 2385 prescriptions, 932 (39%) of which generated an alert for potential intervention. Among the latter, 482 (51.7%) prescriptions prompted direct counselling, mainly for shortening the planned duration of therapy (18.9%), withdrawing antibiotics (16.2%) or streamlining therapy (15.5%). The attending physicians' compliance with the recommendations was 80%. The overall median (interquartile range) days of therapy prescribed by the attending physicians was reduced from an initial duration of 8 (7-14) to 7 (6-11) days (P < 0.0001), resulting in 26.5% less antibiotic days prescribed. The time required for the intervention was 6 h per week. CONCLUSIONS: This computer-prompted post-prescription review led physicians to modify one half of the antibiotic courses initially prescribed and was well accepted by the majority, although they had not requested counselling.

The risk associated with hyperoncotic colloids in patients with shock.

OBJECTIVE: Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypo-oncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician's choice. PARTICIPANTS AND SETTING: International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded. MEASUREMENTS AND RESULTS: Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians' preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24-4.97)] and hyperoncotic albumin [OR: 5.99 (2.75-13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42-5.47)]. CONCLUSIONS: This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist.

Determinant roles of environmental contamination and noncompliance with standard precautions in the risk of hepatitis C virus transmission in a hemodialysis unit.

BACKGROUND: Nosocomial transmission is the second most frequent cause of hepatitis C virus (HCV) infection. A prospective observational study was conducted to assess the roles of environmental contamination and noncompliance with standard precautions in HCV cross-transmission in a hemodialysis unit. METHODS: Patients undergoing chronic hemodialysis in a French university hospital unit were systematically screened, revealing 2 sporadic cases of HCV transmission. An investigation was launched to determine whether the patients were infected in the hemodialysis unit and the possible roles of environmental contamination and noncompliance with standard precautions. We examined possible relationships among new cases of HCV infection, environmental contamination by blood and HCV RNA, and compliance with guidelines on hand hygiene and glove use. RESULTS: Two patients experienced seroconversion to HCV during the study period. Phylogenetic analyses showed that 1 of these patients was infected with the same strain as that affecting a chronically infected patient also treated in the unit. Of 740 environmental surface samples, 82 (11%) contained hemoglobin; 6 (7%) of those contained HCV RNA. The rate of compliance with hand hygiene was 37% (95% confidence interval, 35%-39%), and gloves were immediately removed after patient care in 33% (95% confidence interval, 29%-37%) of cases. A low ratio of nurses to patients and poor hand hygiene were independent predictors of the presence of hemoglobin on environmental surfaces. CONCLUSION: Blood-contaminated surfaces may be a source of HCV cross-transmission in a hemodialysis unit. Strict compliance with hand hygiene and glove use and strict organization of care procedures are needed to reduce the risk of HCV cross-transmission among patients undergoing hemodialysis.

Surgical site infection after surgery to repair femoral neck fracture: a French multicenter retrospective study.

OBJECTIVE: Femoral neck fracture is the most frequent orthopedic emergency among elderly persons. Despite a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in this population, no multicenter study of antibiotic prophylaxis practices and the rate and microbiological characteristics of surgical site infection (SSI) has been performed in France. DESIGN: Retrospective, multicenter cohort study. SETTING: Twenty-two university and community hospitals in France. PATIENTS: Each center provided data on 25 consecutive patients who underwent surgery for femoral neck fracture during the first quarter of 2005. Demographic, clinical, and follow-up characteristics were recorded, and most patients had a follow-up office visit or were involved in a telephone survey 1 year after surgery. RESULTS: These 22 centers provided data on 541 patients, 396 (73%) of whom were followed up 1 year after surgery. Of 504 (93%) patients for whom antibiotic prophylaxis was recorded, 433 (86%) received a cephalosporin. Twenty-two patients had an SSI, for a rate of 5.6% (95% confidence interval, 3.7-8.0). SSI was reported for 15 (6.9%) of patients who had a prosthesis placed and for 7 (3.9%) who underwent osteosynthesis (P=.27). SSI was diagnosed a median of 30 days after surgery (interquartile range, 21-41 days); 7 (32%) of these SSIs were superficial infections, and 15 (68%) were deep or organ-space infections. MRSA caused 7 SSIs (32%), Pseudomonas aeruginosa caused 5 (23%), other staphylococci caused 4 (18%), and other bacteria caused 2 (9%); the etiologic pathogen was unknown in 4 cases (18%). Reoperation was performed for 14 patients with deep or organ-space SSI, including 6 of 7 patients with MRSA SSI. The mortality rate 1 year after surgery was 20% overall but 50% among patients with SSI. In univariate analysis, only the National Nosocomial Infections Surveillance System risk index score was significantly associated with SSI (P=.006). CONCLUSIONS: SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered etiologic pathogen. A large, multicenter prospective trial is necessary to determine whether the use of antibiotic prophylaxis effective against MRSA would decrease the SSI rate in this population.

Benefits and risks of success or failure of noninvasive ventilation.

OBJECTIVE: Noninvasive ventilation (NIV) fails more frequently for de novo acute respiratory failure (de novo) than for cardiogenic pulmonary edema (CPE) or acute-on-chronic respiratory failure (AOC). The impact of NIV failure and success was compared between de novo and CPE or AOC after adjustment for disease severity. SETTINGS: Patients requiring ventilatory support were enrolled in a prospective survey in 70 French ICUs. Of 1076 patients requiring ventilatory support, 524 were eligible, including 299 de novo (NIV use, 30%) and 225 CPE-AOC (NIV use, 55%). DESIGN AND ANALYSIS: Independent risk factors associated with mortality and length of stay were identified by logistic regression analysis. The adjusted outcome of NIV success or failure was compared to that with endotracheal intubation without NIV. RESULTS: NIV success was independently associated with survival in both de novo, adjusted OR 0.05 (95% CI 0.01-0.42), and CPE-AOC OR 0.03 (CI 0.01-0.24). NIV failure was associated with ICU mortality in the de novo group (OR 3.24, CI 1.61-6.53) but not in the CPE-AOC group. Nosocomial pneumonia was less common in patients successful with NIV. NIV failure was associated with a longer ICU stay in CPE-AOC only. The overall use of NIV was independently associated with a better outcome only in CPE-AOC patients (OR 0.33, CI 0.15-0.73). CONCLUSION: The effect of NIV differs between de novo and CPE-AOC patients because NIV failure is associated with increased mortality for de novo patients. This finding should raise a note of caution when applying NIV in this indication.

Association between hand hygiene compliance and methicillin-resistant Staphylococcus aureus prevalence in a French rehabilitation hospital.

We simultaneously investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and compliance with hand hygiene in the clinical wards of a French rehabilitation hospital. We found that the rate of hand hygiene compliance observed at the patient's bedside was a strong predictor of MRSA prevalence.

B-type natriuretic peptide and weaning from mechanical ventilation.

OBJECTIVE: Cardiac function and volume status could play a critical role in the setting of weaning failure. B-type natriuretic peptide (BNP) is a powerful marker of cardiac dysfunction. We assessed the value of BNP during the weaning process. DESIGN, SETTING AND PATIENTS: One hundred and two consecutive patients considered ready to undergo a 1-h weaning trial (T-piece or low-pressure support level) were prospectively included in a medical intensive care unit of a university hospital. Weaning was considered successful if the patient passed the trial and sustained spontaneous breathing for more than 48 h after extubation. INTERVENTIONS: Plasma BNP was measured just before the trial in all patients, and at the end of the trial in the first 60 patients. RESULTS: Overall, 42 patients (41.2%) failed the weaning process (37 patients failed the trial and 5 failed extubation). Logistic regression analysis identified high BNP level before the trial and the product of airway pressure and breathing frequency during ventilation as independent risk factors for weaning failure. BNP values were not different at the end of the trial. In nine of the patients in whom the weaning process failed, it succeeded on a later occasion after diuretic therapy. Their BNP level before weaning decreased between the two attempts (517 vs 226 pg/ml, p=0.01). In survivors, BNP level was significantly correlated to weaning duration (rho=0.52, p<0.01). CONCLUSIONS: Baseline plasma BNP level before the first weaning attempt is higher in patients with subsequent weaning failure and correlates to weaning duration.

Inappropriate prescribing of aminoglycosides: risk factors and impact of an antibiotic control team.

OBJECTIVES: Many factors are involved in the appropriate use of aminoglycosides, such as modalities of administration, drug levels monitoring and duration of treatment. We assessed prospectively the impact of an antibiotic control team on the appropriateness of prescriptions. METHODS: After a first observational audit assessing the appropriateness of prescriptions, and issuing updated recommendations, we performed an interventional audit, where an antibiotic control team provided counselling when prescriptions were considered inappropriate. Appropriateness of prescriptions, clinical outcomes of patients and medical costs were compared between the two periods. RESULTS: One hundred consecutive prescriptions were analysed in each period, and 32% of prescriptions were modified by the control team. As compared with the observational period, prescriptions in the intervention period were more appropriate with regard to treatment duration (73% versus 56%, P = 0.01) and drug levels monitoring (61% versus 40%, P = 0.05), and the median treatment duration was shorter (4 versus 6 days, P = 0.0002). Independent factors associated with appropriate treatment duration were hospitalization in intensive care unit [adjusted odds ratio (aOR), 4.46; 95% confidence interval (CI), 1.60-12.46], polymicrobial infection (aOR, 3.97; 1.32-11.92) and antibiotic control team intervention (aOR, 2.49; 1.27-4.87). The intervention period was associated with lower rate of nephrotoxicity (15% versus 4%, P = 0.01) and lower direct medical costs (4,039.4 Euros per 100 persons treated). CONCLUSIONS: Aminoglycoside use was frequently associated with excessive treatment duration and incorrect drug level monitoring. Reinforcing practice guidelines through direct counselling improved the appropriateness of prescriptions.

Increased use of noninvasive ventilation in French intensive care units.

OBJECTIVES: A prospective survey of French intensive care units (ICUs) in 1997 showed moderate and variable use of noninvasive ventilation (NIV). This study examined changes in NIV use in French ICUs after the intervening 5years. SETTINGS: Patients were enrolled in a prospective survey in 70 French ICUs. METHODS: Three-week survey, with prospective inclusion of all patients requiring ventilatory support. MEASUREMENTS AND RESULTS: Overall 1,076 patients received ventilatory support (55% of admissions). First-line NIV was significantly more common than 5years earlier, overall (23% vs. 16%) and especially in patients not intubated before ICU admission (52% vs. 35%). Reasons for respiratory failure were coma (33%), cardiogenic pulmonary edema (8%), acute-on-chronic respiratory failure (17%), and de novo respiratory failure (41%). Significant increases in NIV use were noted for acute-on-chronic respiratory failure (64% vs. 50%) and de novo respiratory failure (22% vs. 14%). Among patients given NIV, 38% subsequently required endotracheal intubation (not significantly different). Independent risk factors for NIV failure were high SAPS II and de novo respiratory failure, whereas factors associated with success were good NIV tolerance and high body mass index. CONCLUSIONS: NIV use has significantly increased in French ICUs during the past 5years, and the success rate has remained unchanged. In patients not previously intubated, NIV is the leading first-line ventilation modality. The proportion of patients successfully treated with NIV increased significantly over the 5-year period (13% vs. 9% of all patients receiving ventilatory support).

Should electronic faucets be used in intensive care and hematology units?

OBJECTIVE: To compare bacterial contamination associated with electronic faucets and manual faucets in wards admitting patients highly susceptible to infection. DESIGN: Water samples from electronic faucets and manual faucets were taken according to the French recommendations on water surveillance in healthcare settings. SETTING: Hematology and intensive care units (ICUs) of a 900-bed university hospital and a 500-bed general hospital. MEASUREMENTS AND RESULTS: Overall 227 water samples were collected, 92 from electronic faucets and 135 from manual faucets. Thirty-six (39%) of the water samples from electronic faucets and 2 (1%) from manual faucets yielded pathogenic bacteria. In hematology wards 17 (30%) samples from electronic faucets and 2 (2%) from manual faucets were contaminated. In ICUs 19 (53%) samples from electronic faucets and none of 48 from manual faucets were contaminated. All samples were contaminated with various strains of Pseudomonas aeruginosa (8 to >100 CFU/100 ml). Despite hyperchlorination the electronic faucets remained contaminated. Replacing the contaminated electronic faucets by manual faucets led to a complete and sustained elimination of bacterial contamination. Contamination was not associated with a particular brand of electronic faucets. CONCLUSIONS: Our findings demonstrate that electronic faucets are significantly more frequently contaminated than manual faucets and could be a major reservoir for P. aeruginosa. Wards admitting patients highly susceptible to infection and using electronic faucets should be aware of this potential threat. Moreover, units already equipped with these devices, should check water quality periodically.

Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients.

OBJECTIVE: To compare the physiological effects and the clinical efficacy of continuous positive airway pressure (CPAP) vs standard medical treatment in elderly patients (> or =75 years) with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema. DESIGN: A prospective, randomized, concealed, and unblinded study of 89 consecutive patients who were admitted to the emergency departments of one general, and three teaching, hospitals. INTERVENTION: Patients were randomly assigned to receive standard medical treatment alone ( n=46) or standard medical treatment plus CPAP ( n=43). MEASUREMENTS: Improvement in PaO(2)/FIO(2) ratio, complications, length of hospital stay, early 48-h and overall mortality, compared between the CPAP and standard treatment groups. RESULTS: Study groups were comparable with regard to baseline physiological and clinical characteristics (age, sex ratio, autonomy, medical history, cause of pulmonary edema). Within 1 h, noninvasive continuous positive airway pressure led to decreased respiratory rate (respiratory rate, 27+/-7 vs 35+/-6 breaths/min; p=0.009), and improved oxygenation (PaO(2)/F(I)O(2), 306+/-104 vs 157+/-71; p=0.004) compared with baseline, whereas no differences were observed within the standard treatment group. Severe complications occurred in 17 patients in the standard treatment group, vs 4 patients in the noninvasive continuous positive airway pressure group ( p=0.002). Early 48-h mortality was 7% in the noninvasive continuous positive airway pressure group, compared with 24% in the standard treatment group ( p=0.017); however, no sustained benefits were observed during the overall hospital stay. CONCLUSION: Noninvasive continuous positive airway pressure promotes early clinical improvement in elderly patients attending emergency departments for a severe pulmonary edema, but only reduces early 48-h mortality.

Airway colonisation in long-term mechanically ventilated patients. Effect of semi-recumbent position and continuous subglottic suctioning.

OBJECTIVE: To evaluate the impact of continuous subglottic suctioning and semi-recumbent body position on bacterial colonisation of the lower respiratory tract. DESIGN: A randomised controlled trial. SETTING: The ten-bed medical ICU of a French university hospital. PATIENTS: Critically ill patients expected to require mechanical ventilation for more than 5 days. INTERVENTIONS: Patients were randomly assigned to receive either continuous suctioning of subglottic secretions and semi-recumbent body position or to receive standard care and supine position. MEASUREMENTS AND RESULTS: Oropharyngeal and tracheal secretions were sampled daily and quantitatively cultured. All included patients were followed up from day 1 (intubation) to day 10, extubation or death. Ninety-seven samples of oropharynx and trachea were analysed (40 for the suctioning group and 57 for the control group). The median bacterial counts in trachea were 6.6 Log10 CFU/ml (interquartile range, IQR, 4.4-8.3) in patients who received continuous suctioning and 5.1 Log10 CFU/ml (IQR 3.6-5.5) in control patients. Most of the patients were colonised in the trachea after 1 day of mechanical ventilation (75% in the suctioning group, 80% in the control group). No significant difference was found in the daily bacterial counts in the oropharynx and in the trachea between the two groups of patients. CONCLUSION: Tracheal colonisation in long-term mechanically ventilated ICU patients was not modified by the use of continuous subglottic suctioning and semi-recumbent body position.

Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema.

CONTEXT: Randomized controlled trials have shown that the use of noninvasive ventilation (NIV) reduces the need for endotracheal intubation and invasive mechanical ventilation and reduces complication rates and mortality in selected groups of patients. But whether these benefits translate to a clinical setting is unclear. OBJECTIVE: To evaluate longitudinally the routine implementation of NIV and its effect on patients admitted to the intensive care unit (ICU) with acute exacerbation of chronic obstructive pulmonary disease (COPD) or severe cardiogenic pulmonary edema (CPE). DESIGN: Retrospective, observational cohort study using prospectively collected data from January 1, 1994, through December 31, 2001. SETTING: A 26-bed medical intensive care unit (ICU) of a French university referral hospital. PARTICIPANTS: A cohort of 479 consecutive patients ventilated for acute exacerbation of COPD or CPE. MAIN OUTCOME MEASURES: The ICU mortality and incidence rates of ICU-acquired infections. RESULTS: A significant increase in NIV use and a concomitant decrease in mortality and ICU-acquired infection rates were observed over the study years. With adjustment for relevant covariates and propensity scores, NIV was identified as an independent factor linked with a reduced risk of death in the cohort (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.18-0.78), whereas a high severity score on admission (OR, 1.05; 95% CI, 1.01-1.10) and the occurrence of a nosocomial infection (OR, 3.08; 95% CI, 1.62-5.84) were independently associated with death. Rates of ICU-acquired pneumonia decreased from 20% in 1994 to 8% in 2001 (P =.04). CONCLUSION: Implementing routine use of NIV in critically ill patients with acute exacerbation of COPD or severe CPE was associated with improved survival and reduction of nosocomial infections.