IntroductionTracheal intubation in the Intensive Care Unit (ICU) can be challenging as patients often have anatomic and physiologic characteristics that make intubation particularly difficult. Video laryngoscopy (VL) has been shown to improve first attempt success compared to direct laryngoscopy (DL) in many clinical settings and may be an option for ICU intubations.MethodsAll intubations performed in this academic medical ICU during a 13-month period were entered into a prospectively collected quality control database. After each intubation, the operator completed a standardized form evaluating multiple aspects of the intubation including: patient demographics, difficult airway characteristics (DACs), method and device(s) used, medications used, outcomes and complications of each attempt. Primary outcome was first attempt success. Secondary outcomes were grade of laryngoscopic view, ultimate success, esophageal intubations, and desaturation. Multivariate logistic regression was performed for first attempt and ultimate success.ResultsOver the 13-month study period (January 2012-February 2013), a total of 234 patients were intubated using VL and 56 patients were intubated with DL. First attempt success for VL was 184/234 (78.6%; 95% CI 72.8 to 83.7) while DL was 34/56 patients (60.7%; 95% CI 46.8 to 73.5). Ultimate success for VL was 230/234 (98.3%; 95% CI 95.1 to 99.3) while DL was 52/56 patients (91.2%; 95% CI 81.3 to 97.2). In the multivariate regression model, VL was predictive of first attempt success with an odds ratio of 7.67 (95% CI 3.18 to 18.45). VL was predictive of ultimate success with an odds ratio of 15.77 (95% CI 1.92 to 129). Cormack-Lehane I or II view occurred 199/234 times (85.8%; 95% CI 79.5 to 89.1) and a median POGO (Percentage of Glottic Opening) of 82% (IQR 60 to 100) with VL, while Cormack-Lehane I or II view occurred 34/56 times (61.8%; 95% CI 45.7 to 71.9) and a median POGO of 45% (IQR 0 to 78%) with DL. VL reduced the esophageal intubation rate from 12.5% with DL to 1.3% (P = 0.001) but there was no difference in desaturation rates.ConclusionsIn the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

Objective Effective pharmacologic treatments directly targeting lung injury in patients with the acute respiratory distress syndrome (ARDS) are lacking. Early treatment with inhaled corticosteroids and beta agonists may reduce progression to ARDS by reducing lung inflammation and enhancing alveolar fluid clearance. Design Double-blind, randomized clinical trial (ClinicalTrials.gov: NCT01783821). The primary outcome was longitudinal change in oxygen saturation divided by the fraction of inspired oxygen (S/F) through day 5. We also analyzed categorical change in S/F by > 20%. Other outcomes included need for mechanical ventilation and development of ARDS. Setting Five academic centers in the United States. Patients Adult patients admitted through the emergency department at risk for ARDS. Interventions Aerosolized budesonide/formoterol vs. placebo twice daily for up to 5 days. Measurements and Main Results Sixty-one patients were enrolled from September 3, 2013 to June 9, 2015. Median time from presentation to first study drug was < 9 hours. More patients in the control group had shock at enrollment (14 vs 3 patients). The longitudinal increase in S/F was greater in the treatment group (p=0.02) and independent of shock (p=0.04). Categorical change in S/F improved (p=0.01) but not after adjustment for shock (p=0.15). More patients in the placebo group developed ARDS (7 versus 0) and required mechanical ventilation (53% versus 21%). Conclusions Early treatment with inhaled budesonide/formoterol in patients at-risk for ARDS is feasible and improved oxygenation as assessed by S/F. These results support further study to test the efficacy of inhaled corticosteroids and beta agonists for prevention of ARDS.

Summary Study Aims Hyperglycemia is associated with poor outcomes in critically-ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to 1) characterize post-arrest glucose ranges, 2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and 3) identify risk-factors associated with post-arrest glucose derangements. Methods We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007. Results Data were available from 3,218 index events. Maximum blood glucose values were elevated in diabetics (median 226 mg/dL [IQR, 165 – 307 mg/dL], 12.5 mmol/L [IQR 9.2 – 17.0 mmol/L]) and non-diabetics (median 176 mg/dL [IQR, 135 – 239 mg/dL], 9.78 mmol/L [IQR 7.5 – 13.3 mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3 – 47.6%] vs. 41.7% [95% CI, 38.9 – 44.5%], p = .037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71 – 170 mg/dL (3.9 – 9.4 mmol/L) and maximum values outside the range of 111 – 240 mg/dL (6.2 – 13.3 mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240 mg/dL (13.3 mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia. Conclusions Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (> 240 mg/dL, > 13.3 mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (< 70mg/dL, < 3.9 mmol/L).

We identified factors at admission that placed patients at higher risk for developing POH. Select patients may benefit from rapid, aggressive monitoring and resuscitation, possibly preventing POH and its associated morbidity and mortality.

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Sleep-disordered breathing (SDB) comprises a diverse set of disorders marked by abnormal respiration during sleep. Clinicians should realize that SDB may present as acute cardiopulmonary failure in susceptible patients. In this review, we discuss three clinical phenotypes of acute cardiopulmonary failure from SDB: acute ventilatory failure, acute congestive heart failure, and sudden death. We review the pathophysiologic mechanisms and recommend general principles for management. Timely recognition of, and therapy for, SDB in the setting of acute cardiopulmonary failure may improve short- and long-term outcomes.

Background Bronchopleural fistulas (BPF) are conditions associated with prolonged hospital course, high morbidity, and possibly increased mortality. The presence of BPFs in critically ill patients may cause difficulty in ventilation and increased oxygen requirements. Intrabronchial valves (Spiration IBV) serve as a noninvasive therapeutic option for the closure of BPFs. Methods This report is a retrospective description of 3 patients transferred to our medical intensive care unit (ICU) with BPFs and persistent air leaks (PAL). One patient required high levels of oxygen supplementation through a nonrebreather face mask, whereas 2 required mechanical ventilation because of respiratory failure. IBVs were placed in each patient with the intention of closing their BPF and weaning them from respiratory support. Results The use of IBVs in ICU patients with BPFs and PALs resulted in 1 patient being weaned from the persistent need for a nonrebreather face mask to room air and also aided in the liberation from mechanical ventilation of 2 patients who had been failing spontaneous breathing trials. Conclusions The use of IBVs is safe and well tolerated in ICU patients with BPFs and PALs. The placement of IBVs results in significant clinical improvement, allowing for either weaning from high levels of oxygen support or liberation from mechanical ventilation.

Background This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. Methods This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score‐matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score‐matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. Results A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score‐matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498). Conclusion There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast‐induced nephropathy should not be used as a reason to avoid contrast‐enhanced CT.