As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge.

Alveolar overdistention and cyclic reopening of collapsed alveoli have been implicated in the lung damage found in animals submitted to artificial ventilation. To test whether these phenomena are impairing the recovery of patients with acute respiratory distress syndrome (ARDS) submitted to conventional mechanical ventilation (MV), we evaluated the impact of a new ventilatory strategy directed at minimizing "cyclic parenchymal stretch." After receiving pre-established levels of hemodynamic, infectious, and general care, 28 patients with early ARDS were randomly assigned to receive either MV based on a new approach (NA, consisting of maintenance of end-expiratory pressures above the lower inflection point of the P x V curve, VT < 6 ml/kg, peak pressures < 40 cm H2O, permissive hypercapnia, and stepwise utilization of pressure-limited modes) or a conventional approach (C = conventional volume-cycled ventilation, VT = 12 ml/kg, minimum PEEP guided by FIO2 and hemodynamics and normal PaCO2 levels). Fifteen patients were selected to receive NA, exhibiting a better evolution of the PaO2/FIO2 ratio (p < 0.0001) and of compliance (p = 0.0018), requiring shorter periods under FIO2 > 50% (p = 0.001) and a lower FIO2 at the day of death (p = 0.0002). After correcting for baseline imbalances in APACHE II, we observed a higher weaning rate in NA (p = 0.014) but not a significantly improved survival (overall mortality: 5/15 in NA versus 7/13 in C, p = 0.45). We concluded that the NA ventilatory strategy can markedly improve the lung function in patients with ARDS, increasing the chances of early weaning and lung recovery during mechanical ventilation.

This study shows that renal dysfunction has serious consequences in the duration of mechanical ventilation, weaning from mechanical ventilation, and mortality in critically ill cancer patients.

PURPOSE: Invasive mechanical ventilation is associated with complications, and its abbreviation is desirable. The imbalance between increased workload, decreased inspiratory muscle strength and endurance is an important determinant of ventilator dependence. Low endurance may be present due to respiratory muscle atrophy, critical illness, or steroid use. Specific inspiratory muscle training may increase or preserve endurance. The objective of the study was to test the hypothesis that inspiratory muscle training from the beginning of mechanical ventilation would abbreviate the weaning duration and decrease reintubation rate. As a secondary objective, we described the evolution of inspiratory muscle strength with and without inspiratory muscle training. METHODS: Prospective, randomized clinical trial in an adult clinical-surgical intensive care unit. Twelve patients trained the inspiratory muscles twice a day, and 13 patients did not (control). Training was performed adjusting the sensitivity of the ventilator based on the maximal inspiratory pressure. Patients underwent daily surveillance of the maximal inspiratory pressure. RESULTS: The weaning duration (31 ± 22 hr, control and 23 ± 11 hr, training group; P = .24) and reintubation rate (5 control and 3 training group; P = .39) were not statistically different. The maximal inspiratory pressure of the control group showed a trend toward a modest increase. In contrast, the training group showed a small decrease (P = .34). CONCLUSIONS: In acute critically ill patients, inspiratory muscle training from the beginning of mechanical ventilation neither abbreviated the weaning duration, nor decreased the reintubation rate. Inspiratory muscle strength tended to stay constant, along the mechanical ventilation, with or without this specific inspiratory muscle training.

Summary. Objectives: Although effective strategies for the prevention of venous thromboembolism (VTE) are widely available, a significant number of patients still develop VTE because appropriate thromboprophylaxis is not correctly prescribed. We conducted this study to estimate the risk profile for VTE and the employment of adequate thromboprophylaxis procedures in patients admitted to hospitals in the state of Sa˜o Paulo, Brazil. Methods: Four hospitals were included in this study. Data on risk factors for VTE and prescription of pharmacological and non-pharmacological thromboprophylaxis were collected from 1454 randomly chosen patients (589 surgical and 865 clinical). Case report forms were filled according to medical and nursing records. Physicians were unaware of the survey. Three risk assessment models were used: American College of Chest Physicians (ACCP) Guidelines, Caprini score, and the International Union of Angiololy Consensus Statement (IUAS). The ACCP score classifies VTE risk in surgical patients and the others classify VTE risk in surgical and clinical patients. Contingency tables were built presenting the joined distribution of the risk score and the prescription of any pharmacological and non-pharmacological thromboprophylaxis (yes or no). Results: According to the Caprini score, 29% of the patients with the highest risk for VTE were not prescribed any thromboprophylaxis. Considering the patients under moderate, high or highest risk who should be receiving prophylaxis, 37% and 29% were not prescribed thromboprophylaxis according to ACCP (surgical patients) and IUAS risk scores, respectively. In contrast, 27% and 42% of the patients at low risk of VTE, according to Caprini and IUAS scores, respectively, had thromboprophylaxis prescribed. Conclusion: Despite the existence of several guidelines, this study demonstrates that adequate thromboprophylaxis is not correctly prescribed: high-risk patients are under-treated and low-risk patients are over-treated. This condition must be changed to insure that patients receive adequate treatment for the prevention of thromboembolism.

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Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP.

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