Lung protective ventilation strategy for the acute respiratory distress syndrome.

BACKGROUND: Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung-protective ventilation strategies may lead to improved survival. OBJECTIVES: To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used. SEARCH STRATEGY: In our original review, we searched databases from inception until 2003. In this updated review, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library 2006, Issue 3). We updated our search of MEDLINE, EMBASE, CINAHL and the Web of Science from 2003 to 2006. We also updated our search of intensive care journals and conference proceedings; databases of ongoing research, reference lists and 'grey literature' from 2003 to 2006. SELECTION CRITERIA: We included randomized controlled trials comparing ventilation using either lower tidal volume (Vt) or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in tidal volume of 7 ml/kg or less versus ventilation that uses Vt in the range of 10 to 15 ml/kg, in adults (16 years old or older). DATA COLLECTION AND ANALYSIS: We independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We applied fixed- and random-effects models. MAIN RESULTS: We found one new study in this update for a total of six trials, involving 1297 patients, which were eligible for inclusion. Mortality at day 28 was significantly reduced by lung-protective ventilation: relative risk (RR) 0.74 (95% confidence interval (CI) 0.61 to 0.88); hospital mortality was reduced: RR 0.80 (95% CI 0.69 to 0.92); overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in control group was used: RR 1.13 (95% CI 0.88 to 1.45). There was insufficient evidence about morbidity and long term outcomes. AUTHORS' CONCLUSIONS: Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials, make the interpretation of the combined results difficult. Mortality is significantly reduced at day 28 and at the end of hospital stay. The effects on long-term mortality are unknown, although the possibility of a clinically relevant benefit cannot be excluded.

Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung-protective ventilation strategies may lead to improved survival. OBJECTIVES: To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 4, 2003; MEDLINE (1966 to October 2003); EMBASE and CINAHL (1982 to October 2003); intensive care journals and conference proceedings; databases of ongoing research, reference lists and 'grey literature'. SELECTION CRITERIA: Randomized trials comparing ventilation using either lower tidal volume or low airway driving pressure (plateau pressure 30 cm H(2)O or less), resulting in tidal volume of 7 ml/kg or less versus ventilation that uses Vt in the range of 10 to 15 ml/kg, in adults (aged 16 years or older). DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. Fixed and random effects models were applied. MAIN RESULTS: Five trials, involving 1202 patients, were eligible. Mortality at day 28 was significantly reduced by lung-protective ventilation: relative risk 0.74 (confidence interval 0.61 to 0.88), whereas beneficial effect on long-term mortality was uncertain: relative risk 0.84 (confidence interval 0.68 to 1.05). The comparison between low and conventional tidal volume was not significantly different if a plateau pressure less than or equal to 31 cm H2O in control group was used: relative risk 1.13 (confidence interval 0.88 to 1.45). There was insufficient evidence about morbidity and long term outcomes. REVIEWERS' CONCLUSIONS: Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials make the interpretation of the combined results difficult. Mortality is significantly reduced at day 28 and the effects on long term mortality are uncertain, although the possibility of a clinically relevant benefit cannot be excluded.

Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Patients with acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) require mechanical ventilatory support. ALI/ARDS is further complicated by ventilator-induced lung injury. Lung-protective ventilation strategies may lead to improved survival. OBJECTIVES: To assess the effects of ventilation with lower tidal volume (Vt) on morbidity and mortality in adults patients affected by ALI/ARDS. A secondary objective was to determine whether the comparison between low and conventional Vt is different if a plateau airway pressure of greater than 30 to 35 cm H20 was used. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 3, 2002; MEDLINE (1966 to June 2002); EMBASE and CINAHL (1982 to June 2002); intensive care journals and conference proceedings; databases of ongoing research, reference lists and 'grey literature'. SELECTION CRITERIA: Randomized trials comparing ventilation using lower Vt and/or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in Vt of 7 ml/kg or less versus ventilation that uses Vt in the range of 10 to 15 ml/kg, in adults (16 year-old or greater). DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. Fixed and random effects models were applied. MAIN RESULTS: Five trials, involving 1202 patients, were eligible. The test for heterogeneity gave a P-value of 0.12. Ventilation with lower Vt was associated with a decreased mortality at the end of the follow up period for each trial: 216/605 (35.7%) versus 249/597 (41.7%), relative risk (RR) 0.85 (CI 0.74 to 0.98). The effect of the intervention was not statistically significant when a random effects model was used: RR 0.91 (CI 0.72 to 1.14). Mortality at day 28 was significantly reduced by lung-protective ventilation: RR 0.74 (CI 0.61 to 0.88). The comparison between low and conventional Vt was not significantly different if a plateau pressure less than or equal to 31 cm H2O in control group was used: RR 1.13 (CI 0.88 to 1.45). There was insufficient evidence about morbidity and long term outcomes. REVIEWER'S CONCLUSIONS: Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials make the interpretation of the combined results difficult. Mortality is significantly reduced at day 28 and the effects on long term mortality are uncertain, although the possibility of a clinically relevant benefit cannot be excluded. There is no evidence that low Vt ventilation is beneficial in patients where hypercapnia is potentially harmful.

[Survival of 213 patients who recovered in resuscitation from cardiac arrest]. / Studio sulla sopravvivenza di 213 pazienti ricoverati in Rianimazione per arresto cardiaco.

213 patients who received in-hospital cardiopulmonary resuscitation (CPR) were studied over a period of five years (1985-89) to determine hospital and long-term survival. The following factors were evaluated in determining outcome: age, ECG on admission, clinical history, year, month, hour of admission. A 5-year survival table was complied for all discharged from hospital. The results showed that age, clinical history, month and hour of admission were not influencing factors; asystole as opposed to ventricular fibrillation was however associated with significantly higher in-hospital mortality (p less than 0.005). Hospital survival was 14.6% with an ascendant range from 1986 to 1989 (p less than 0.05); all the patients were discharged mentally unimpaired with over 50% surviving 1.5 years after discharge and 33% 5 years after. The study shows that the highest cause of cardiac arrest is ischaemic cardiopathy in male patients with an average age of 60 years. Total neurological recovery after CPR was confirmed to be a determinant predictor factor of survival.

[Control of the side effects of ketamine: chlordemethyldiazepam vs diazepam in pre-anesthesia]. / Controllo degli effetti collaterali della ketamina: clordemetildiazepam vs diazepam in preanestesia.

The pre-operative circulatory and psychotomimetic side-effects are studied in one hundred patients undergoing elective plastic-reconstructive surgery and anesthetized by ketamine 5-8 mg/kg i.m. Fifty patients were premedicated by atropine 0.01 mg/kg + CDDz 0.0285 mg/kg i.m. (group C), fifty by atropine 0.01 mg/kg + Dz 0.14 mg/kg i.m. (group D). All patients breathed spontaneously. Statistical analysis was performed with X 2 test. Not statistical difference was observed for the circulatory side-effects, whereas the frequency of emergence phenomena fell significantly from 31% to 14% (p less than 0.05) with CDDZ in greater than 16 years old patients. These finding seem confirm that CDDZ is more effective than DZ in reducing the psychotomimetic side-effects of ketamine, though it may be recommended a its wider experiment in this connection.