Respiratory Failure & Mechanical Ventilation

I completed Quiz: 2️⃣ Control Variables!

I completed 2️⃣ Control Variables!

I completed 1️⃣ Breath Phases!

Notice that what it seems to be a right pneumothorax is actually bullae on the CT scan. Let pneumothorax is under pressure and chest tube was inserted!

However, on the CT scan taken post chest tube insertion, it seems that the tube is introduced into the lung!

Bilateral pulmonary masses, biopsy positive for adenocarcinoma.

Swelling in both hands and face associated with shortness of breath.

Chest tube drained around 1600 mL of yellowish clear fluid.

Bronchoscopy shows severe narrowing in the righ main bronchus, unable to pass the scope.

CXR 5 days ago:

CXR today

CT scan after intubation:

Loculated pneumothorax!

Bilateral apical pneumothoraces, approximately 10% in size on the right and 20-30% on the left without mediastinal shift with diffuse alveolar infiltrates and air bronchograms.

HOT COVID Trial

Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19: The HOT-COVID Randomized Clinical Trial | Coronavirus (COVID-19) | JAMA | JAMA Network

In a multicenter trial involving 726 adults with COVID-19 and severe hypoxemia in European ICUs, targeting a partial pressure of oxygen (Pao2) of 60 mm Hg led to a median of 80 days alive without life support at 90 days, compared to 72 days for a Pao2 of 90 mm Hg (P=.009). No significant difference in mortality or serious adverse events was observed between the groups. This suggests that in severe COVID-19, a lower oxygenation target may improve outcomes without increasing risk.

HOT COVID Trial

Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19: The HOT-COVID Randomized Clinical Trial | Coronavirus (COVID-19) | JAMA | JAMA Network

In a multicenter trial involving 726 adults with COVID-19 and severe hypoxemia in European ICUs, targeting a partial pressure of oxygen (Pao2) of 60 mm Hg led to a median of 80 days alive without life support at 90 days, compared to 72 days for a Pao2 of 90 mm Hg (P=.009). No significant difference in mortality or serious adverse events was observed between the groups. This suggests that in severe COVID-19, a lower oxygenation target may improve outcomes without increasing risk.

Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial – A Randomized Clinical Trial | American Journal of Respiratory and Critical Care Medicine (atsjournals.org)

In a U.S. trial involving 41 institutions and 113 patients with exacerbations of chronic obstructive pulmonary disease (COPD), the impact of extracorporeal CO2 removal (ECCO2R) on reducing ventilation time was assessed. The study, aiming for a sample size of 180, was prematurely halted due to slow enrollment. It explored whether ECCO2R could increase ventilator-free days within the first 5 days post-randomization. Participants were divided into those failing noninvasive ventilation (NIV, n=48) and those difficult to wean from invasive mechanical ventilation (IMV, n=65), receiving either standard care with ECCO2R or standard care alone.

Results revealed no statistically significant difference in median ventilator-free days at 5 days post-randomization between treatment arms across both strata (P=0.36). Specifically, in the NIV group,…

Videolaryngoscope versus Conventional Technique for Insertion of a Transesophageal Echocardiography Probe in Intubated ICU Patients (VIDLARECO trial). A Randomized Clinical trial - ScienceDirect

In a trial with 100 intubated critically ill patients, the use of a videolaryngoscope for transesophageal echocardiogram probe insertion significantly increased first-attempt success rates (90% vs. 58%, p < 0.001) and overall success (100% vs. 72%, p < 0.001), compared to the conventional method. Additionally, the videolaryngoscope group experienced notably fewer pharyngeal complications (14% vs. 52%, p < 0.001), demonstrating its efficacy and safety over traditional techniques in this patient population.

Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial | American Journal of Respiratory and Critical Care Medicine | Articles in Press (atsjournals.org)

This US trial, involving 113 COPD exacerbation patients, aimed to evaluate ECCO2R's effectiveness against standard care. The study, intended for 180 patients, was prematurely stopped due to slow enrollment. Results showed no significant improvement in ventilator-free days at Day 5 with ECCO2R. Specifically, in the non-invasive ventilation stratum, ECCO2R and standard care both recorded a median of 5 ventilator-free days, while in the invasive ventilation stratum, ECCO2R resulted in slightly more ventilator-free days (2 days vs 0.25 days), but without statistical significance. Notably, ECCO2R was associated with a higher in-hospital mortality rate in the non-invasive group (22% vs 0%).

64 years old male who is a heavy smoker with COPD and laryngeal carcinoma, s/p tracheostomy. He is addmitted now to the ICU complaining of air hunger. When connected to the ventilator; it showed the waves you see and the patient felt suffocation. Unfortunately, this is the only screenshot that was provided by Dr. Abdulhaseeb Tarabulsi.

Knowing that this is not a ventilator malfunction or circuit disconnection, what do you thing is happening?

Ventilator graphic of an intubated asthmatic patient on mechanical ventilation showing mild persistent flow at end of expiration indicating auto-PEEP:

The ventilator settings were changed as the following:

VT decreased from 470 to 420 mL.

Rate decreased from 20 to 16 breaths per minute but the patient is still breathing over.

The inspiratory time was decreased from 0.9 second to 0.6 second.