BACKGROUND: Infants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge.
METHODS: We conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007-July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts.
RESULTS: Post-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05).
CONCLUSIONS: Standardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH.
METHODS: III.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is reportedly associated with air leak syndrome (ALS), including mediastinal emphysema and pneumothorax, and has a high mortality rate. In this study, we compared values obtained every minute from ventilators to clarify the relationship between ventilator management and risk of developing ALS.
METHODS: This single-center, retrospective, observational study was conducted at a tertiary care hospital in Tokyo, Japan, over a 21-month period. Information on patient background, ventilator data, and outcomes was collected from adult patients with SARS-CoV-2 pneumonia on ventilator management. Patients who developed ALS within 30 days of ventilator management initiation (ALS group) were compared with those who did not (non-ALS group).
RESULTS: Of the 105 patients, 14 (13%) developed ALS. The median positive-end expiratory pressure (PEEP) difference was 0.20 cmH2O (95% confidence interval [CI], 0.20-0.20) and it was higher in the ALS group than in the non-ALS group (9.6 [7.8-20.2] vs. 9.3 [7.3-10.2], respectively). For peak pressure, the median difference was -0.30 cmH2O (95% CI, -0.30 - -0.20) (20.4 [17.0-24.4] in the ALS group vs. 20.9 [16.7-24.6] in the non-ALS group). The mean pressure difference of 0.0 cmH2O (95% CI, 0.0-0.0) (12.7 [10.9-14.6] vs. 13.0 [10.3-15.0], respectively) was also higher in the non-ALS group than in the ALS group. The difference in single ventilation volume per ideal body weight was 0.71 mL/kg (95% CI, 0.70-0.72) (8.17 [6.79-9.54] vs. 7.43 [6.03-8.81], respectively), and the difference in dynamic lung compliance was 8.27 mL/cmH2O (95% CI, 12.76-21.95) (43.8 [28.2-68.8] vs. 35.7 [26.5-41.5], respectively); both were higher in the ALS group than in the non-ALS group.
CONCLUSIONS: There was no association between higher ventilator pressures and the development of ALS. The ALS group had higher dynamic lung compliance and tidal volumes than the non-ALS group, which may indicate a pulmonary contribution to ALS. Ventilator management that limits tidal volume may prevent ALS development.

Acute respiratory failure requiring invasive mechanical ventilation is a common presentation in the emergency department. Providers can further improve care for these patients by understanding common modes of mechanical ventilation, recognizing changes in respiratory mechanics, and tailoring ventilator settings and therapies accordingly.

The reported case is of a 68-year-old man who was admitted to the ICU at our tertiary care medical center with severe COVID-19. He was admitted to the ICU due to a worsening respiratory condition during his hospitalization at the same medical center, which included the development of severe acute respiratory distress syndrome (ARDS). Ventilator management was started with alveolar protection in mind. On the ninth day of ventilator management, we judged that it was necessary to introduce extracorporeal membrane oxygenation (ECMO). Although the ninth day of ventilator management is considered relatively late for starting ECMO, there are no absolute contraindications for ECMO at this stage, and improvements in oxygenation can be expected. After introducing ECMO, the patient\'s oxygenation capacity improved, and ECMO was successfully withdrawn within 16 days. The patient required long-term rehabilitation but was discharged from the hospital to his home without lingering disease complications on the 150th day of illness and subsequently resumed his former work, daily activities, and quality of life. We conclude that, in regard to the introduction of ECMO for ARDS, it is necessary to reach a comprehensive judgment without being bound by any one index (such as the ventilation management period prior to ECMO introduction).

BACKGROUND: Patients requiring endotracheal intubation and mechanical ventilation in the emergency department (ED) are critically ill, and their ventilator management is crucial for their subsequent clinical outcomes. Lung-protective ventilation (LPV) setting strategies are key considerations for this care. The objectives of this 2019-2020 community-based quality improvement project were to: a) identify patients at greater risk of not receiving LPV, and b) evaluate the effectiveness of a series of brief quality improvement educational sessions to improve LPV setting protocol adherence rates.
METHODS: A 15-month retrospective chart review of ventilator settings and subject characteristics (N = 200) was conducted before and after a series of 10-15-minute educational sessions were delivered to improve LPV adherence. This information was presented at a series of four educational sessions for 25 attending physicians (n = two sessions) and 27 residents at conferences (n = two sessions). Two additional materials (e.g., LPV reference charts, tape measures to gauge patients\' heights) were also posted in three ED resuscitation rooms and on cabinets containing emergency airway equipment. The pre and post-intervention occurrence rates of LPV setting orders were inferentially compared before and after educational sessions.
RESULTS: Patients ventilated using LPV increased from 70% to 82% after the educational sessions (p = 0.04). All patients who were 67 inches or greater in height were ventilated appropriately before and after sessions. For patients under 65 inches in height, post-session LPV adherence increased from 13% to 53% (p = 0.01).
CONCLUSIONS: Based on these results, a brief ED provider educational intervention can significantly improve the utilization of LPV guideline-based settings. Patients under 65 inches in height may also be especially at risk of receiving non-LPV ventilator setting orders.

The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery.
Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality.
Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH2O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009).
The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC.
Clinicaltrials.gov , identifier: NCT01601223.

We herein report a case in which the trachea could be completely sealed only when the cuff pressure reached 100 cmH2O. An excessive cross-sectional area of the trachea is a rare phenomenon, but we believe that our case will be helpful for clinicians who encounter similar situations.

Preventing exposure of virulent pathogens during aerosolizing procedures such as intubations has been a cause of concern during the coronavirus pandemic. As such, protocols have been adjusted and precautions implemented in order to minimize the risk to the proceduralist. As patients improve, we face another high-risk aerosolizing procedure-extubation. We illustrate a protocol to help minimize the exposure risk during extubation. We describe a barrier technique during extubation which contained aerosolized particulates into a non-rebreather mask at time of extubation. Our protocol allows providers to perform extubations while minimizing exposure to aerosolized particles.

When the coronavirus disease 2019 (COVID-19) pandemic was declared, it was clear that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) would have far-reaching impacts on medicine, society and everyday life. As a junior doctor working closely with patients with SARS-CoV-2 infection, I was aware of my personal risk of exposure to the virus. I assumed that as a fit and well 26-year-old with no comorbidities, if I were to become infected, it was unlikely that COVID-19 would be severe. However, I became critically unwell following a week of clinical work, necessitating hospital admission, tracheal intubation and mechanical ventilation. I remained mechanically ventilated for 6 days and was then transferred to a medical ward 2 days later. After two further days of rehabilitation, I was discharged home. This reflection is not a junior doctor\'s view of how COVID-19 was managed by the NHS, but a personal view of my illness from \'the other side of the curtain\'. My reflections focus upon the psychological aspects of my experiences, exploring the memories that I formed around the time of critical care, how the fears that I possessed were managed with exceptional communication, and the importance of the wider healthcare team in my recovery.

Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.