2009 Oct - Exhaled Air Dispersion Distances During Noninvasive Ventilation via Different Respironics Face Masks

David S. Hui, MD, FCCP, Benny K. Chow, MPH, Susanna S. Ng, MBChB, Leo C. Y. Chu, MBChB, Stephen D. Hall, PhD, Tony Gin, MD, Joseph J. Y. Sung, MD and Matthew T. V. Chan, MD. CHEST October 2009 vol. 136 no. 4 998-1005. 
Background: As part of our influenza pandemic preparedness, we studied the exhaled air dispersion distances and directions through two different face masks (Respironics; Murrysville, PA) attached to a human-patient simulator (HPS) during noninvasive positive-pressure ventilation (NPPV) in an isolation room with pressure of −5 Pa.

Read more ...

2009 Sep - Characteristics of Children Intubated and Mechanically Ventilated in 16 PICUs

Robinder G. Khemani, MD, MsCI, Barry P. Markovitz, MD, MPH and Martha A. Q. Curley, PhD, RN. CHEST September 2009 vol. 136 no. 3 765-771
Background: When designing multicenter clinical trials, it is important to understand the characteristics of children who have received ventilation in PICUs.

Methods: This study involved the secondary analysis of an existing data set of all children intubated and mechanically ventilated from 16 US PICUs who were initially screened for a multicenter clinical trial on pediatric acute lung injury (ALI).

Read more ...

2009 Sep - Age, Duration of Mechanical Ventilation, and Outcomes of Patients Who Are Critically Ill

Yan Feng, MD, PhD, Yaw Amoateng-Adjepong, MD, PhD, David Kaufman, MD, Cristina Gheorghe, MD and Constantine A. Manthous, MD, FCCP. CHEST September 2009 vol. 136 no. 3 759-764
Background: Age and duration of mechanical ventilation (MV) are strongly associated with mortality and hospital discharge disposition.

Methods: Electronic administrative records from a 425-bed community teaching hospital were obtained for 9,912 patients who were admitted to hospital ICUs between 2003 and 2008. Risk estimates of age and duration of MV for in-hospital mortality and discharge to home vs extended-care facilities (ECFs) also were obtained.

Read more ...

2009 Sep - Epidemiology and Outcomes of Clostridium difficile-Associated Disease Among Patients on Prolonged Acute Mechanical Ventilation

Marya D. Zilberberg, MD, MPH, FCCP, Brian H. Nathanson, PhD, Shamil Sadigov, MS, Thomas L. Higgins, MD, MBA, Marin H. Kollef, MD, FCCP and Andrew F. Shorr, MD, MPH, FCCP. CHEST September 2009 vol. 136 no. 3 752-758
Purpose: Patients receiving prolonged acute mechanical ventilation (PAMV), although comprising a third of all mechanical ventilation (MV) patients, consume two-thirds of all the resources allocated to MV, and their numbers are projected to double by 2020. By virtue of their prolonged hospital length of stay (median LOS, 17 days), they are subject to such nosocomial infections as Clostridium difficile-associated disease (CDAD), the incidence and age-adjusted case fatality rate of which doubled between 2000 and 2005. We examined the rates and outcomes of CDAD among adult PAMV patients.

Methods: We analyzed 2005 data from the Health Care Utilization Project/Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. PAMV and CDAD were identified using the International Classification of Diseases, ninth revision, clinical modification codes 96.72 and 008.45, respectively.

Read more ...

2009 Aug - Relationship Between Vascular Endothelial Growth Factor + 936 Genotype and Plasma/Epithelial Lining Fluid Vascular Endothelial Growth Factor Protein Levels in Patients With and at Risk for ARDS

Andrew R. L. Medford, MD, Sofia I. H. Godinho, PhD, Leigh J. Keen, PhD, Jeffrey L. Bidwell, PhD and Ann B. Millar, MD. CHEST August 2009 vol. 136 no. 2 457-464
Background: Vascular endothelial growth factor (VEGF) is postulated to have a role in ARDS. The functional VEGF + 936 polymorphic T allele is associated with an increased susceptibility to and severity of ARDS. The reasons for this are unclear. We hypothesized that the T allele would be associated with an alteration in the relation between epithelial lining fluid (ELF) and plasma VEGF levels as a potential explanation for its association with susceptibility to and severity of ARDS.

Methods: Plasma and ELF VEGF protein levels were measured by enzyme-linked immunosorbent assay from 10 at-risk patients receiving mechanical ventilation and 16 ARDS patients with the T allele, as well as 18 at-risk patients receiving mechanical ventilation and 26 ARDS patients without the T allele (wild-type CC genotype).

Read more ...

2009 Aug - Plasma C-Reactive Protein Levels Are Associated With Improved Outcome in ARDS

Ednan K. Bajwa, MD, MPH, Uzma A. Khan, MD, James L. Januzzi, MD, Michelle N. Gong, MD, MS, B. Taylor Thompson, MD and David C. Christiani, MD, MPH, FCCP. CHEST August 2009 vol. 136 no. 2 471-480
Background: C-reactive protein (CRP) has been studied as a marker of systemic inflammation and outcome in a number of diseases, but little is known about its characteristics in ARDS. We sought to examine plasma levels of CRP in patients with ARDS and their relationship to outcome and measures of illness severity.

Methods: We measured CRP levels in 177 patients within 48 h of disease onset and tested the association of protein level with 60-day mortality, 28-day daily organ dysfunction scores, and number of ventilator-free days.

Read more ...

2009 Aug - Terminal Withdrawal of Mechanical Ventilation at a Long-term Acute Care Hospital: Comparison With a Medical ICU

Alexander C. White, MD, FCCP, Bernard Joseph, MD, Arvind Gireesh, MD, Priya Shantilal, MD, Erik Garpestad, MD, FCCP, Nicholas S. Hill, MD, FCCP and Heidi H. O'Connor, MD, FCCP. CHEST August 2009 vol. 136 no. 2 465-470
Background: Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU).

Methods: A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n = 30) and in a MICU (n = 74) over a 2-year period.

Read more ...

2009 Aug - Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU

Phillip D. Levin, MB BChir, Olga Shatz, MD, Sigal Sviri, MD, Dvora Moriah, RN, Adi Or-Barbash, MD, Charles L. Sprung, MD, FCCP, Allon E. Moses, MD and Colin Block, MDCHEST August 2009 vol. 136 no. 2 426-432
Background: Approximately 15% of nosocomial infections in the ICU result from spread of bacteria on caregivers' hands. The routine chest radiograph provides an unexamined opportunity for bacterial spread: close contact with each patient and sequential examination of ICU patients. This study examined infection control procedures performed during routine chest radiographs, assessed whether resistant bacteria were transferred to the radiograph machine, and determined whether improved infection control practices by radiograph technicians could reduce bacterial transfer.

Methods: Radiograph technicians were observed performing chest radiographs on all ICU patients. Culture specimens were taken from the radiograph machine. An educational intervention directed at technicians was instituted, and its effect on infection control and machine contamination was measured.

Read more ...

2009 Aug - Bilevel vs ICU Ventilators Providing Noninvasive Ventilation: Effect of System Leaks: A COPD Lung Model Comparison

Juliana C. Ferreira, MD, Daniel W. Chipman, RRT, Nicholas S. Hill, MD, FCCP and Robert M. Kacmarek, PhD, RRT; CHEST August 2009 vol. 136 no. 2 448-456
Background: Noninvasive positive-pressure ventilation (NPPV) modes are currently available on bilevel and ICU ventilators. However, little data comparing the performance of the NPPV modes on these ventilators are available.

Methods: In an experimental bench study, the ability of nine ICU ventilators to function in the presence of leaks was compared with a bilevel ventilator using the IngMar ASL5000 lung simulator (IngMar Medical; Pittsburgh, PA) set at a compliance of 60 mL/cm H2O, an inspiratory resistance of 10 cm H2O/L/s, an expiratory resistance of 20 cm H2O/ L/s, and a respiratory rate of 15 breaths/min. All of the ventilators were set at 12 cm H2O pressure support and 5 cm H2O positive end-expiratory pressure. The data were collected at baseline and at three customized leaks.

Read more ...

2009 Nosocomial Pneumonia Risk and Stress Ulcer Prophylaxis: A Comparison of Pantoprazole vs Ranitidine in Cardiothoracic Surgery Patients

Miano TA, Reichert MG, Houle TT, Macgregor DA, Kincaid EH, Bowton DL.; Chest. 2009 136: 440-447

Background: Stress ulcer prophylaxis (SUP) using ranitidine, a histamine H2 receptor antagonist, has been associated with an increased risk of ventilator-associated pneumonia. The proton-pump inhibitor pantoprazole is also commonly used for SUP. Proton-pump inhibitor use has been linked to an increased risk of community-acquired pneumonia. The objective of this study was to determine whether SUP with pantoprazole increases pneumonia risk compared to ranitidine in critically ill patients.

Read more ...

2009 A Randomized Trial of Dental Brushing for Preventing Ventilator-Associated Pneumonia

Pobo A, Lisboa T, Rodriguez A, Sole R, Magret M, Trefler S, Gómez F, Rello J.; Chest August 2009 136:433-439; published ahead of print May 29, 2009

Background: Poor oral hygiene is associated with respiratory pathogen colonization and secondary lung infection. The impact of adding electric toothbrushing to oral care in order to reduce VAP incidence is unknown.

Read more ...

2009 Bilevel vs ICU Ventilators Providing Noninvasive Ventilation, Effect of System Leaks: A COPD Lung Model Comparison

Ferreira JC, Chipman DW, Hill NS, Kacmarek RM.; Chest August 2009 136:448-456; published ahead of print May 8, 2009

Background: Noninvasive positive pressure ventilation (NPPV) modes are currently available on bi-level and ICU ventilators. However, little data comparing the performance of the NPPV modes on these ventilators is available.

Read more ...

2009 Structured approaches to pain management in the ICU [Review]

Recommended by Dr SHUM Hoi Ping, ICU, Pamela Youde Nethersole Eastern Hospital, Hong Kong, on 9 July 2009
Pasero C, Puntillo K, Li D, Mularski RA, Grap MJ, Erstad BL, Varkey B, Gilbert HC, Medina J, Sessler CN;
Chest. 2009 Jun;135(6):1665-72. 

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts.

Read more ...

2009 American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography

Presented by Dr KWAN Ming Chit Arthur at the Daily Journal Club of ICU, PYNEH, Hong Kong, on 5 June 2009
Paul H. Mayo, MD*, Yannick Beaulieu, MD, Peter Doelken, MD, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography. Published online before print February 2009, doi: 10.1378/chest.08-2305. CHEST April 2009 vol. 135 no. 4 1050-1060
Editor's notes: The article contains useful tables which can be used as a syllabus or checklist to assess competence in various ultrasonography techniques, including echocardiography.

Objective: To define competence in critical care ultrasonography (CCUS).

Design: The statement is sponsored by the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de Réanimation de Langue Française (SRLF). The ACCP and the SRLF selected a panel of experts to review the field of CCUS and to develop a consensus statement on competence in CCUS.

Read more ...

2009 Heparin-Induced Thrombocytopenia - A Contemporary Clinical Approach to Diagnosis and Management

Eduard Shantsila, MD*, Gregory Y. H. Lip, MD and Beng H. Chong, MD
CHEST June 2009 vol. 135 no. 6 1651-1664

Thrombocytopenia following heparin administration can be associated with an immune reaction, now referred to as heparin-induced thrombocytopenia (HIT). HIT is essentially a prothrombotic disorder mediated by an IgG antiplatelet factor 4/heparin antibody, which induces platelet, endothelial cell, monocyte, and other cellular activation, leading to thrombin generation and thrombotic complications. Indeed, HIT can also be regarded as a serious adverse drug effect. Importantly, HIT can be a life-threatening and limb-threatening condition frequently associated with characteristically severe and extensive thromboembolism (both venous and arterial) rather than with bleeding. This article provides an overview of HIT, with an emphasis on the clinical diagnosis and management.

Read more ...

2009 Oropharyngeal Cleansing With 0.2% Chlorhexidine for Prevention of Nosocomial Pneumonia in Critically Ill Patients: An Open-Label Randomized Trial With 0.01% Potassium Permanganate as Control

CHEST May 2009 vol. 135 no. 5 1150-1156

Tanmay S. Panchabhai, MBBS, Neha S. Dangayach, MBBS, Anand Krishnan, MD, Vatsal M. Kothari, MD and Dilip R. Karnad, MD*  

*From the Medical-Neuro Intensive Care Unit, Department of Medicine, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India.
A part of this work was presented at CHEST 2008, Philadelphia, PA.

Figure. Left: 0.2% chlorhexidine mouthwash, Right: Potassium permanganate crystals

Background: Oral cleansing with chlorhexidine decreases the incidence of nosocomial pneumonia in patients after cardiac surgery. However, evidence of its benefit in ICU patients is conflicting.

Methods: Patients admitted to the ICU of an Indian tertiary care teaching hospital were randomized to twice-daily oropharyngeal cleansing with 0.2% chlorhexidine or 0.01% potassium permanganate (control) solution. Effects on the incidence of nosocomial pneumonia during ICU stay (primary outcome) and length of ICU stay and in-hospital mortality (secondary outcomes) were studied.


Read more ...

2009 Prolonged Acute Mechanical Ventilation - Implications for Hospital Benchmarking

CHEST May 2009 vol. 135 no. 5 1157-1162
Marya D. Zilberberg, MD, MPH, FCCP*, Andrew A. Kramer, PhD, Thomas L. Higgins, MD, MBA and Andrew F. Shorr, MD, MPH, FCCP

*From the School of Public Health and Health Sciences (Dr. Zilberberg), University of Massachusetts, Amherst, MA; Cerner Corporation (Dr. Kramer), Kansas City, MO; the Division of Critical Care Medicine (Dr. Higgins), Baystate Medical Center, Springfield, MA; and the Division of Pulmonary and Critical Care (Dr. Shorr), Washington Hospital Center, Washington, DC. 

Background: Hospital performance measures rely on aggregate outcomes. For patients receiving mechanical ventilation (MV), outcomes depend on severity of illness, hospital MV volume, and case mix. Patients requiring prolonged acute MV (PAMV) [MV for ≥ 96 h] comprise a resource-intensive group, but the impact of its volume on aggregate outcomes is unknown. We investigated whether observed outcomes differed from those predicted by APACHE (acute physiology and chronic health evaluation) IV risk adjustment and the relationship between hospital MV volume and outcomes among patients receiving PAMV.

Methods: We conducted a retrospective cohort study using the APACHE IV database between the years 2001 and 2005.


Read more ...


CHEST, May 1, 2008; 133 (5 suppl)

Asha Devereaux, Michael D. Christian, Jeffrey R. Dichter, James A. Geiling, and Lewis Rubinson Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007* Chest May 2008 133:1S-7S; doi:10.1378/chest.08-0649

Michael D. Christian, Asha V. Devereaux, Jeffrey R. Dichter, James A. Geiling, and Lewis Rubinson Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations* Chest May 2008 133:8S-17S; doi:10.1378/chest.07-2707

Lewis Rubinson, John L. Hick, Dan G. Hanfling, Asha V. Devereaux, Jeffrey R. Dichter, Michael D. Christian, Daniel Talmor, Justine Medina, J. Randall Curtis, and James A. Geiling Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity Chest May 2008 133:18S-31S; doi:10.1378/chest.07-2690

Lewis Rubinson, John L. Hick, J. Randall Curtis, Richard D. Branson, Suzi Burns, Michael D. Christian, Asha V. Devereaux, Jeffrey R. Dichter, Daniel Talmor, Brian Erstad, Justine Medina, and James A. Geiling Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity* Chest May 2008 133:32S-50S; doi:10.1378/chest.07-2691

Asha V. Devereaux, Jeffrey R. Dichter, Michael D. Christian, Nancy N. Dubler, Christian E. Sandrock, John L. Hick, Tia Powell, James A. Geiling, Dennis E. Amundson, Tom E. Baudendistel, Dana A. Braner, Mike A. Klein, Kenneth A. Berkowitz, J. Randall Curtis, and Lewis Rubinson Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care* Chest May 2008 133:51S-66S; doi:10.1378/chest.07-2693

Click Read More to go to CHEST.


Read more ...

2008 Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares [Review]

Marik PE, Baram M, Vahid B. Chest. 2008 Jul;134(1):172-8

Video: Estimating JVP during physical exam (Video Link from YouTube). Don't lose this medical art, though also bearing in mind its limitations, even if a more accurate central venous pressure is obtained by invasive means.


Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients. Both historical and recent data suggest that this approach may be flawed. OBJECTIVE: A systematic review of the literature to determine the following: (1) the relationship between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the ability of the change in CVP (DeltaCVP) to predict fluid responsiveness.

Read more ...