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4 results

  • Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic

  • David C. Leisten, Jennifer Wheeler, James Boomhower, Michael A. Frakes, Todd Denison, Jason E. Cohen, Susan R. Wilcox
  • Journal:
    Prehospital and Disaster Medicine / Volume 36 / Issue 6 / December 2021
    Published online by Cambridge University Press:
    22 September 2021, pp. 762-766
    Print publication:
    December 2021

  • The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.

  • Mechanical Ventilation with Room Air is Feasible in a Moderate Acute Respiratory Distress Syndrome Pig Model – Implications for Disaster Situations and Low-Income Nations

  • Pinchas Halpern, Michael Goldvaser, Guy Yacov, Amir Rosner, Ada Wenger, Keren Bachar, Shahaf Katalan
  • Journal:
    Prehospital and Disaster Medicine / Volume 35 / Issue 6 / December 2020
    Published online by Cambridge University Press:
    27 August 2020, pp. 604-611
    Print publication:
    December 2020
  • Introduction:

    Patients with respiratory failure are usually mechanically ventilated, mostly with fraction of inspired oxygen (FiO2) > 0.21. Minimizing FiO2 is increasingly an accepted standard. In underserved nations and disasters, salvageable patients requiring mechanical ventilation may outstrip oxygen supplies.

    Study Objective:

    The hypothesis of the present study was that mechanical ventilation with FiO2 = 0.21 is feasible. This assumption was tested in an Acute Respiratory Distress Syndrome (ARDS) model in pigs.

    Methods:

    Seventeen pigs were anesthetized, intubated, and mechanically ventilated with FiO2 = 0.4 and Positive End Expiratory Pressure (PEEP) of 5cmH2O. Acute Respiratory Distress Syndrome was induced by intravenous (IV) oleic acid (OA) infusion, and FiO2 was reduced to 0.21 after 45 minutes of stable moderate ARDS. If peripheral capillary oxygen saturation (SpO2) decreased below 80%, PEEP was increased gradually until maximum 20cmH2O, then inspiratory time elevated from one second to 1.4 seconds.

    Results:

    Animals developed moderate ARDS (mean partial pressure of oxygen [PaO2]/FiO2 = 162.8, peak and mean inspiratory pressures doubled, and lung compliance decreased). The SpO2 decreased to <80% rapidly after FiO2 was decreased to 0.21. In 14/17 animals, increasing PEEP sufficed to maintain SpO2 > 80%. Only in 3/17 animals, elevation of FiO2 to 0.25 after PEEP reached 20cmH2O was needed to maintain SpO2 > 80%. Animals remained hemodynamically stable until euthanasia one hour later.

    Conclusions:

    In a pig model of moderate ARDS, mechanical ventilation with room air was feasible in 14/17 animals by elevating PEEP. These results in animal model support the potential feasibility of lowering FiO2 to 0.21 in some ARDS patients. The present study was conceived to address the ethical and practical paradigm of mechanical ventilation in disasters and underserved areas, which assumes that oxygen is mandatory in respiratory failure and is therefore a rate-limiting factor in care capacity allocation. Further studies are needed before paradigm changes are considered.

  • Chapter 28 - Cancer

  • from Section 4 - The pregnant patient with coexisting disease
  • Edited by Marc van de Velde, Helen Scholefield, Lauren A. Plante
  • Book:
    Maternal Critical Care
    Published online:
    05 July 2013
    Print publication:
    04 July 2013, pp 313-321

  • Summary

    This chapter deals with issues related to mechanical ventilation in general and considers those relevant to the obstetric patient in particular. The most common modes of mechanical ventilation are: volume-controlled continuous mandatory ventilation (VC-CMV), pressure-controlled continuous mandatory ventilation (PC-CMV), intermittent mandatory ventilation (IMV), continuous mandatory ventilation (CMV), airway pressure release ventilation (APRV) and positive end-expiratory pressure (PEEP). All patients receiving mechanical ventilation should be monitored by pulse oximetry. Non-invasive ventilation can be delivered nasally or by face mask, using either a conventional mechanical ventilator or a machine designed specifically for this purpose. The 2009 H1N1 influenza pandemic and the particular susceptibility of pregnancy in such circumstances reinforce the need to appraise the rationale for mechanical ventilation in such patients. Finally, APRV as a ventilatory paradigm, in particular, may be particularly useful in the pregnant patient with pneumonits, acute lung injury, or acute respiratory distress syndrome (ARDS).

  • Chapter 35 - Autoimmune disease in pregnancy

  • from Section 4 - The pregnant patient with coexisting disease
  • Edited by Marc van de Velde, Helen Scholefield, Lauren A. Plante
  • Book:
    Maternal Critical Care
    Published online:
    05 July 2013
    Print publication:
    04 July 2013, pp 391-402

  • Summary

    Various physiological changes occur as a result of the pregnant state, affecting patients with pre-existing lung disease and affecting the assessment and management of the patient with respiratory failure. Asthma, pulmonary infections, tuberculosis are some of the conditions not specific to pregnancy. Acute severe asthma in pregnancy may be treated as in the non-pregnant patient with intravenous beta- 2-adrenergic agonists, intravenous theophylline, intravenous magnesium sulfate and steroids. Standard drug therapy, namely with isoniazid, rifampin, and ethambutol has an acceptable safety profile in pregnancy and is recommended for pregnant women by the US Centers for Disease Control and Prevention and the American Thoracic Society. Acute respiratory distress syndrome (ARDS) occurs fairly frequently in pregnancy and is a leading cause of maternal death. Several approaches to respiratory support, including conventional mechanical ventilation, airway pressure release ventilation, high-frequency oscillation, and extracorporeal membrane oxygenation, have been used successfully in pregnancy.