Chronic microaspiration through a tracheal cuff is the main culprit in the penetration and colonization of the lower respiratory tract. A total of 145 patients intubated for more than 3 days were randomly assigned to a double nosocomial pneumonia (NP) prevention: 1--Prevention of aspiration by hourly subglottic secretion drainage (SSD) with a specific endotracheal tube (HI-LO Evac tube, Mallinckrodt); 2--Prevention of gastric colonization using either sucralfate or antacids. Four random groups were defined, similar in age and severity of illness. Subglottic secretion drainage treatment was associated with: a) a twice lower incidence of NP (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3 +/- 5 days, SSD: 16.2 +/- 11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD: +21.3%, SSD: +6.6%) and in subglottic secretions (no-SSD: +33.4%, SSD: +2.1%). Sucralfate was not associated with a significantly lower incidence of NP (antacids: 23.6%, sucralfate: 17.8%), but with a lower increase in the colonization rate in subglottic and gastric aspirates, from admission to end-point day.

These results emphasize the need for applying various infection control measures to prevent colonization of patients with P. aeruginosa, including strategies to limit the potential of sinks from acting as a source or reservoir for this bacterium.

Among 1532 ICU patients we analysed 295 elderly patients (19%) aged more than 70-years-old. We determined prospectively the immediate and subsequent one-year outcome with a study of the predictive value of their ICU admission parameters. Then we followed the ICU survivors over the year after discharge (1, 6, 12 months) by quality of life questionnaires. ICU mortality was 26.7%; SAPS was the only predictor of short term mortality. On ICU discharge, 216 elderly were followed at 1, 6, 12 months; the one-year cumulative mortality was 49% from ICU discharge, majority of deaths occurring over the first month. Age, previous health status and SAPS had a predictor value of one-year mortality for ICU survivors. 103 patients were alive at one year: 88% returned to home, 72% had a relatively good functional status allowing an independent life, and 82% had the same or improved functional status.

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Sensitivity of US and MC, respectively, was 50% and 67%, specificity 94% and 100%, positive predictive value 86% and 100%, negative predictive value 71% and 80%, and accuracy 75% and 86%. The correlation between US and MC findings was 71%, with chi = 0.31. By Bayesian analysis the probability of disease if the MC finding was positive was 100% regardless of US results. A positive US finding was associated with a 86% probability of disease, but with a probability of only 66% in case of negative MC results. MC is thus superior to US for confirming AAC in selected critically ill patients. Nevertheless, US is an easy, noninvasive, and effective method of bedside screening. The combination of the two imaging tests improves diagnostic accuracy and reduces false-positive and false-negative rates. Poor agreement between the two tests leads to better diagnostic complementarity.

In summary, only 56.6% of ICU patients receiving SAT had CP. Most strains were susceptible to SAT. A similar 28-day mortality rate was observed among groups; the late administration of SAT significantly worsened the prognosis of patients with less severe CP.

Inspiratory muscle unloading decreases ventilatory drive. In this study, we examined the time course of this effect in patients with chronic obstructive pulmonary disease receiving two modes of ventilatory support: pressure support ventilation (PSV), during which each cycle was assisted, and biphasic positive airway pressure (BIPAP), set up in such a manner that one spontaneous breath took place between two consecutive pressure-assisted breaths. The first breath following the switch from spontaneous breathing to PSV was associated with an increase in tidal volume (VT) and a drop in mean transdiaphragmatic pressure (mean Pdi) and inspiratory work (WI) performed per liter but with unchanged values of esophageal occlusion pressure at 100 ms (Pes 0.1), diaphragmatic electrical activity (EMGdi), and WI performed by breath. The same phenomena were observed for the assisted breath of BIPAP as compared with the preceding spontaneous breath. During the subsequent breaths of PSV, Pes 0.1, EMGdi, and WI performed per breath decreased progressively up to the sixth to eighth breaths, and VT returned to pre-PSV values. We conclude that in patients with chronic obstructive pulmonary disease the decrease in ventilatory drive associated with PSV takes place from the first breath onwards but requires six to eight breaths to be fully achieved. During BIPAP, as a consequence of the kinetics of the PSV-induced downregulation of ventilatory drive, assisted breaths following spontaneous breaths are characterized by an enhanced inspiratory efficiency.

The study results show that cervical epidural analgesia provides marginally better pain relief at rest with no decrease in the fentanyl consumption. The use of the cervical epidural administration of fentanyl is questionable because of the possible complications of the technique.