Untitled

Abstract

New therapies are challenging older, established practices. One recently published report shows us that we may be able to avoid endotracheal intubation in patients with a reduced level of consciousness. Recombinant activated factor VII is proving to be useful in many coagulation disorders, and intracerebral haemorrhage can be added to this list. Homeopathy, in the form of potassium dichromate, shows promise as a new treatment for excessive tracheal secretions. Rotation protocols for antibiotics have been evaluated with respect to their ability to prevent the development of new resistant micro-organisms in our hospitals and units. Finally, glucocorticoids may be of benefit to septic patients outside the intensive care unit (ICU) and may prevent their deterioration and admission to the ICU.Intensive care medicine is a relatively new medical speciality and so it is inevitable that established practices based on expert opinion (level V evidence) will be challenged. The use of noninvasive positive pressure ventilation (NiPPV) to treat acute respiratory failure (ARF) is a treatment that is often contraindicated in patients with reduced consciousness level because of the risk for aspiration. This concept has been challenged by Diaz and coworkers [1] in a recent report published in Chest. Those investigators conducted a prospective, open, uncontrolled study to assess primarily the success (defined as avoidance of endotracheal intubation, and survival to 24 hours after intensive care unit [ICU] discharge) of NiPPV therapy for ARF in patients with a Glasgow Coma Scale (GCS) score of 8 or below versus those with a GCS score above 8. Secondarily, they aimed to identify variables that would predict failure of NiPPV in these patients.A total of 958 patients were recruited into the study, of whom 95 had a GCS score of 8 or below [1]. The results revealed greater success for NiPPV in the comatose group (80.0% versus 70.1%; P = 0.043). However, ARF secondary to chronic obstructive airways disease (COAD) appeared to respond better than ARF of other causes, such as acute respiratory distress syndrome and pneumonia, and this was seen in a higher percentage of the comatose group, which might have accounted for the better outcome. Hospital mortality was similar between groups. Of the 95 coma patients recruited, aspiration occurred once, and this patient went on to require intubation. Factors predicting hospital survival in the comatose patients included a lower Acute Physiology and Chronic Health Evaluation II score and respiratory rate, as well as initiation of therapy in the emergency department rather than in the ICU. This paper provides further evidence of the importance of early initiation of therapy, before ICU admission, as was described in the landmark report by Rivers and coworkers [2].Recombinant activated factor VII (rVIIa), although not yet widely used, is a new drug that may be considered in the management of many types of bleeding and coagulation disorders in the future. Because of the new surface-based model fo...