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Now showing items 1 - 16 of 24

  • Inability of Diaphragm Ultrasound to Predict Extubation Failure

    Vivier, Emmanuel   Muller, Michel   Putegnat, Jean-Baptiste   Steyer, Julie   Barrau, Stéphanie   Boissier, Florence   Bourdin, Gaël   Mekontso-Dessap, Armand   Levrat, Albrice   Pommier, Christian   Thille, Arnaud W.  

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    Frat, Jean-Pierre   Ragot, Stéphanie   Coudroy, Rémi   Robert, René   Thille, Arnaud W.  

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    Coudroy, Rémi   Frat, Jean-Pierre   Boissier, Florence   Contou, Damien   Robert, René   Thille, Arnaud W.  

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  • Ten reasons to be more attentive to patients when setting the ventilator

    Thille, Arnaud W.   Roche-Campo, Ferran   Brochard, Laurent  

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  • Weaning from the ventilator and extubation in ICU

    Thille, Arnaud W.   Cortés-Puch, Irene   Esteban, Andrés  

    Purpose of review The decision to extubate is a crucial moment for intubated patients. In most cases, the transition to spontaneous breathing is uneventful, but in some patients, it implies a more challenging decision. Both extubation delay and especially the need for reintubation are associated with poor outcomes. We aim to review the recent literature on weaning and to clarify the role of certain interventions intending to help in this process. Recent findings Cardiac dysfunction is probably one of the most common causes of weaning failure. Several studies have evaluated the ability of B-natriuretic peptides and echocardiographic tools to predict weaning outcome due to cardiac origin, attempting to prevent its failure. Noninvasive ventilation may have a potential benefit in preventing respiratory failure after extubation of hypercapnic patients, although more studies are needed to define a target population. Summary Current research is focusing on preventing extubation failure, especially in the most challenging cases. The use of weaning protocols - written or computerized - attempts to early identify patients who are able to breathe spontaneously and to hasten extubation, resulting in better outcomes. Nevertheless, individualized care is needed in the most vulnerable patients, trying to prompt weaning without exposing patients to unnecessary risks.
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  • The Decision to Extubate in the Intensive Care Unit

    Thille, Arnaud W.   Richard, Jean-Christophe M.   Brochard, Laurent  

    The day of extubation is a critical time during an intensive care unit (ICU) stay. Extubation is usually decided after a weaning readiness test involving spontaneous breathing on a T-piece or low levels of ventilatory assist. Extubation failure occurs in 10 to 20% of patients and is associated with extremely poor outcomes, including high mortality rates of 25 to 50%. There is some evidence that extubation failure can directly worsen patient outcomes independently of underlying illness severity. Understanding the pathophysiology of weaning tests is essential given their central role in extubation decisions, yet few studies have investigated this point. Because extubation failure is relatively uncommon, randomized controlled trials on weaning are underpowered to address this issue. Moreover, most studies evaluated patients at low risk for extubation failure, whose reintubation rates were about 10 to 15%, whereas several studies identified high-risk patients with extubation failure rates exceeding 25 or 30%. Strategies for identifying patients at high risk for extubation failure are essential to improve the management of weaning and extubation. Two preventive measures may prove beneficial, although their exact role needs confirmation: one is noninvasive ventilation after extubation in high-risk or hypercapnic patients, and the other is steroid administration several hours before extubation. These measures might help to prevent postextubation respiratory distress in selected patient subgroups.
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  • Outcomes of extubation failure in medical intensive care unit patients*

    Thille, Arnaud W.   Harrois, Anatole   Schortgen, Frédérique   Brun-Buisson, Christian   Brochard, Laurent  

    Objective: Extubation failure is associated with a poor prognosis, but the respective roles for reintubation per se and underlying disease severity remain unclear. Our objectives were to evaluate the impact of failed extubation, whether planned or unplanned, on patient outcomes and to identify a patient subset at risk for extubation failure. Design: Prospective 1-yr observational study with daily data collection. Setting: Thirteen-bed medical intensive care unit in a teaching hospital. Patients: Consecutive patients requiring invasive mechanical ventilation were screened and followed until discharge or death. Interventions: None. Measurements and Main Results: Of 168 planned extubations in 340 patients, 26 (15%) failed. Of these 26 patients, seven (27%) had pneumonia and 13 (50%) died after reintubation. Compared with successfully extubated patients, the patients with failed extubation were not significantly different regarding disease se-verity, mechanical ventilation duration, or blood gas values. Age and underlying diseases were the only factors associated with extubation failure, and extubation failure occurred in 34% of patients >65 yrs with chronic cardiac or respiratory disease compared with only 9% of other patients (p < .01). Unplanned extubation occurred in 9% of patients, and inadequate endotracheal tube position was a risk factor. Failure of both planned and unplanned extubation was specifically associated with significant rapid worsening of daily organ dysfunction scores. Conclusions: Patients >65 yrs with underlying chronic cardiac or respiratory disease are at high risk for extubation failure and subsequent pneumonia and death. Contrasting with successful extubation, failed planned or unplanned extubation was followed by marked clinical deterioration, suggesting a direct and specific effect of extubation failure and reintubation on patient outcomes. (Crit Care Med 2011; 39:2612-2618)
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  • International Analgesia, Sedation, and Delirium Practices: a prospective cohort study

    Owen, Gary D.   Stollings, Joanna L.   Rakhit, Shayan   Wang, Li   Yu, Chang   Hosay, Morgan A.   Stewart, James W.   Frutos-Vivar, Fernando   Peñuelas, Oscar   Esteban, Andres   Anzueto, Antonio R.   Raymondos, Konstantinos   Rios, Fernando   Thille, Arnaud W.   González, Marco   Du, Bin   Maggiore, Salvatore M.   Matamis, Dimitrios   Abroug, Fekri   Amin, Pravin   Zeggwagh, Amine Ali   Patel, Mayur B.  

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  • Risk Factors for and Prediction by Caregivers of Extubation Failure in ICU Patients

    Thille, Arnaud W.   Boissier, Florence   Ben Ghezala, Hassen   Razazi, Keyvan   Mekontso-Dessap, Armand   Brun-Buisson, Christian  

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  • Comparison of the Berlin Definition for Acute Respiratory Distress Syndrome with Autopsy

    Thille, Arnaud W.   Esteban, Andrés   Fernández-Segoviano, Pilar   Rodriguez, José-Maria   Aramburu, José-Antonio   Pe?uelas, Oscar   Cortés-Puch, Irene   Cardinal-Fernández, Pablo   Lorente, José A.   Frutos-Vivar, Fernando  

    Rationale: A revised definition of clinical criteria for acute respiratory distress syndrome (ARDS), the Berlin definition, was recently established to classify patients according to their severity. Objective: To evaluate the accuracy of these clinical criteria using diffuse alveolar damage (DAD) at autopsy as the reference standard. Methods: All patients who died and had a clinical autopsy in our intensive care unit over a 20-year period (1991-2010) were included. Patients with clinical criteria for ARDS were identified from the medical charts and were classified as mild, moderate, or severe according to the Berlin definition using Pa-O2/Fl(O2) oxygenation criteria. Microscopic analysis from each pulmonary lobe was performed by two pathologists. Measurements and Main Results: Among 712 autopsies analyzed, 356 patients had clinical criteria for ARDS at time of death, classified as mild (n = 49, 14%), moderate (n = 141,40%), and severe (n = 166, 46%). Sensitivity was 89% and specificity 63% to identify ARDS using the Berlin definition. DAD was found in 159 of 356 (45%) patients with clinical criteria for ARDS (in 12, 40, and 58% of patients with mild, moderate, and severe ARDS, respectively). DAD was more frequent in patients who met clinical criteria for ARDS during more than 72 hours and was found in 69% of those with severe ARDS for 72 hours or longer. Conclusions: Histopathological findings were correlated to severity and duration of ARDS. Using clinical criteria the revised Berlin definition for ARDS allowed the identification of severe ARDS of more than 72 hours as a homogeneous group of patients characterized by a high proportion of DAD.
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  • Promoting Patient-Ventilator Synchrony

    Thille, Arnaud W.   Brochard, Laurent  

    Patient-ventilator asynchrony, in which the patient's inspiration fails to coincide exactly with the ventilator's insufflation, is common in clinical practice. Studies suggest that nearly one-fourth of intubated patients exhibit frequent asynchrony during assisted ventilation. Frequent asynchrony is associated with longer duration of mechanical ventilation, because it may reflect not only greater disease severity, but also inappropriate ventilator settings. New-generation ventilators with large screens facilitate the detection of gross asynchronies by careful examination of flow and airway-pressure tracings. The main asynchrony is ineffective triggering, defined as failure of a patient's inspiratory effort to trigger a ventilator breath. Ineffective triggering is caused by dynamic hyperinflation at the time of a triggering attempt. Other major asynchronies include double triggering, in which 2 consecutive ventilator cycles are triggered by a single patient effort; and auto-triggering, in which the ventilator is triggered by signals that do not come from the patient. More discreet asynchronies such as prolonged insufflation during pressure-support ventilation or inadequate flow rate during assist-control ventilation can also be suspected from the flow and airway-pressure traces. Simple delays in triggering or cycling are extremely common but difficult to detect. Optimizing the ventilator settings, most notably by reducing ventilatory support or insufflation time, can minimize ineffective triggering. New ventilatory modes such as proportional-assist ventilation and neurally adjusted ventilatory assist may improve patient-ventilator synchrony. Whether optimizing ventilation shortens the duration of mechanical ventilation by reducing the occurrence of asynchrony is still an open question.
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  • Alveolar Recruitment in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome

    Thille, Arnaud W.   Richard, Jean-Christophe M.   Maggiore, Salvatore M.   Ranieri, V Marco   Brochard, Laurent  

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  • At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

    Thille, Arnaud W.   Boissier, Florence  

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  • Impact of sleep alterations on weaning duration in mechanically ventilated patients: a prospective study

    Thille, Arnaud W.   Reynaud, Faustine   Marie, Damien   Barrau, Stéphanie   Rousseau, Ludivine   Rault, Christophe   Diaz, Véronique   Meurice, Jean-Claude   Coudroy, Rémi   Frat, Jean-Pierre   Robert, René   Drouot, Xavier  

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  • Does the Berlin definition for acute respiratory distress syndrome predict the presence of diffuse alveolar damage?

    Thille, Arnaud W.   Vuylsteke, Alain   Bersten, Andrew  

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  • Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study

    Thille, Arnaud W.   Boissier, Florence   Ben-Ghezala, Hassen   Razazi, Keyvan   Mekontso-Dessap, Armand   Brun-Buisson, Christian   Brochard, Laurent  

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