Introduction: Optimal cuff pressure for intubated patients is 20-30 cm H 2 O as routinely measured by manometry. This methodology is associated with elevated costs due to equipment requirements. The objective of this study was to evaluate another methodology, i.e., the minimal leak testing (MLT). Materials and methods: Initial cuff pressures were measured by manometry for all mechanically ventilated patients in a surgical intensive care unit (ICU). Two critical care physicians separately performed an MLT for each subject and cuff pressure was then remeasured by manometry. The rate of ventilator-associated pneumonia (VAP) was determined. Results: Thirty subjects with 100 patient events were evaluated. The post-MLT measured cuff pressures were highly consistent between physicians, with a Pearson correlation coefficient of 0.770 (p = 0.01). Average initial cuff pressures were not significantly different between manometry and MLT (25 cm H 2 O vs 14 cm H 2 O, p = 0.1894). Manometry had a higher incidence of elevated cuff pressures (n = 13/50 vs 2/100, p < 0.0001), while MLT had higher incidences low cuff pressures (n = 72/100 vs 17/50, p < 0.0001). No difference was observed in the VAP rate (2.8 vs 3.0 per 1,000 ventilator days, p = 0.96). Conclusion: Minimal leak testing is a known method of cuff pressure monitoring that was demonstrated in this study to provide a reproducible technique.
Introduction:The purpose of this study was to compare the use of t-PA and t-PA + Dornase for the management of complicated pleural effusions and to determine if a dose-response relationship exists for t-PA. Methods: Retrospective cohort study that examined all adult patients at the University of Colorado Hospital who received t-PA or t-PA + Dornase for the management of a complicated pleural effusion from September 2011 to December 2012. Outcomes were success of therapy [defined as avoidance of secondary interventions (i.e. VATS or decortication)], chest tube output, radiographic findings, t-PA dose, and bleeding. Results: Thirty-five patients were enrolled: 25 received t-PA and 10 received t-PA + Dornase. Overall, patients were 53 ± 21 years old and 51% were male. Infection was the primary cause of pleural effusions (52% in t-PA vs 80% in t-PA + Dornase group). No differences in demographics were observed between groups. Successful pharmacologic treatment occurred in 88% of patients receiving t-PA and 100% of patients receiving t-PA + Dornase (p=0.54). In the t-PA group, chest tube output increased from 75 ml/day to 538 ml/day after administration of t-PA (p=0.001), and from 103 ml/day to 502 ml/day (p=0.001) in the t-PA + Dornase group. Radiographic improvement occurred in 84% of t-PA patients and 90% of t-PA + Dornase patients (p=0.99). In the t-PA group, a successful response occurred in 90% of patients receiving a cumulative dose of ≤ 20 mg (n=21) and 67% of patients receiving a cumulative dose of > 20 mg (n=3). There was 100% success rate in the t-PA + Dornase group with a median cumulative t-PA dose of 40 mg (range 20-100mg). Administration of fibrinolytic therapy did not result in increased bleeding risk. Conclusions: Both t-PA and t-PA + Dornase were highly effective for reducing a patient's need for surgical intervention. A cumulative t-PA dose of >20 mg did not appear to provide additional benefit.
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