Medical Inspection – Health Blog

From March 1986 through November 1987, 106 blunt trauma patients were randomized to receive either a conventional hospital bed or the RRKTT. Seven patients who were in the SICU for <24 h were excluded from the analyses. Another 13 patients were randomized to the study group, but were either never put on the oscillating bed or were taken off the RRKTT prematurely (ie, prior to discharge from the SICU). During the initial few months of the study, several patients with lower extremity injuries requiring traction were randomized to the oscillating bed group, but were not placed on the RRKTT because of objections raised by attending orthopedic surgeons. As institutional familiarity with the bed increased, this problem resolved. During the entire course of the study, several patients spent one or more days on the study bed, but because of problems encountered were later switched to a conventional bed while still in the RRKTT group in the SICU. These problems included: compression of unstable facial fractures (particularly those involving the zygomatic arch); concerns about the effect of the bed on intracranial pressure; and patient intolerance of the beds rotation and confining aspects. Most patients were rotated 40° bilaterally for 10 to 16 h per day.

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This study was approved by the Committee on the Protection of Human Subjects in Research at the University of Massachusetts Medical Center. Verbal informed consent was obtained from patients or responsible third parties within 24 h of entry into the trial.

Patients were eligible for entry into the trial if they had serious nonpenetrating injuries and were likely to require care in the SICU for more than 24 h. Within 24 h of admission to the SICU, patients were randomly allocated to care using a conventional hospital bed or to care using a RRKTT (Kinetic Concepts, Inc, San Antonio, TX). The treatment group for a particular patient was determined by opening the appropriate sequentially numbered opaque envelope containing the patients group assignment. The randomization schedule was generated using a table of random numbers. We prospectively excluded patients with unstable spine injuries because we considered it unethical to use a conventional bed for patients with these problems. Retrospectively excluded were patients (n = 7) who were discharged from the SICU within 24 h of admission.

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Tnfectious complications are an important cause of morbidity and late mortality after major trauma. Lower respiratory tract infections, ie, pneumonia and tracheobronchitis, occur commonly in critically ill victims of head trauma, thoracic trauma, spinal cord trauma and other severe injuries. The increased risk of LRTI in these patients is almost certainly a consequence of multiple factors, including systemic alterations in immune competence, impaired muco­ciliary clearance in the tracheobronchial tree, pul­monary edema secondary to direct injury to the lung, diffuse lung injury (ie, adult respiratory distress syndrome), and gastric alkalinization with antacids and/or H₂-antagonists.

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The lack of change in parameters of pulmonary function and arterial blood gas values during a period of 11 h of spontaneous breathing in four of our patients indicates that our patients remained stable off the ventilator and that blood gas levels obtained at mid­day or late during the period of spontaneous ventilation are representative of the patients sustained level of ventilation. This stability during the period of spon­taneous ventilation also demonstrates that evidence of respiratory muscle fatigue did not occur between intervals of assisted ventilation.

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In our series of eight patients with Duchenne or Duchenne-type muscular dystrophy with respiratory failure, we found, as others have, that nocturnal ventilatory assistance using noninvasive ventilators brought about a sustained reversal of hypoventilation and improvement in symptoms of chronic hypercarbia. The clinical course was stabilized in most patients who required infrequent hospitalizations despite min­imal pulmonary reserve. Although our patients tried a variety of negative and positive pressure ventilators, they preferred negative pressure ventilators and par­ticularly the tank ventilator because it was effective, comfortable and left the upper airway free. Recently, however, as others have reported, we have had success in assisting ventilation in patients with mus­cular dystrophy and other restrictive lung diseases using positive pressure ventilation administered via a nose mask.

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Following initiation of nocturnal ventilatory assis­tance, five of our eight patients required only one hospitalization for respiratory problems and one pa­tient had no hospitalizations in more than five years. Patient 6 required repeated hospitalizations because of inability to clear secretions and patient 2 had multiple hospitalizations, several related to his severe underlying cardiomyopathy. Three patients died dur­ing the extended follow-up period, one of pneumonia when he declined endotracheal intubation. The other two had severe cardiomyopathy and experienced sud­den death, one while using the iron lung. Autopsies were not performed.

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Table 1 shows age at initiation of assisted ventilation, respiratory parameters at initiation of assisted venti­lation and at times of early and extended follow-up and clinical outcome in the eight patients comprising our series. Most patients developed respiratory failure at approximately 20 years of age, as is typical for Duchenne muscular dystrophy. Delayed onset in pa­tients 1 and 6 suggests that they may have had a more slowly progressing variety. All patients had severe restriction of their vital capacities and severe hyper- carbia at the time that ventilatory assistance was initiated.

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