Chest
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We successfully implemented the delivery of noninvasive mechanical ventilation for patients with acute respiratory failure, a previously controversial use of this technique, using a simplified ventilator (BiPAP) with nasal mask. Pilot work showed this mode of support to be effective when administered by the members of a research team, and in the current study we were able to transfer this responsibility to usual care providers. ⋯ Withdrawal of ventilatory support for greater than 48 h (successful outcome) was about the same during usual care (phase 3, 80 percent) as it was during special care (phase 1, 76 percent).
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In patients with blunt chest trauma, early diagnosis of mediastinal hematoma is important, because it could be associated with thoracic vessel injury. Mediastinal hematoma is generally evoked because of a widened mediastinum on chest radiograph, but radiologic diagnosis may lead to excessive angiography being performed. Transesophageal echocardiography (TEE) provides accurate views of the mediastinum and can be rapidly performed at the bedside. ⋯ We described three different TEE signs of mediastinal hematoma: (1) an increased distance between the probe and the aortic wall; (2) a double contour of the aortic wall; and (3) visualization of the ultrasound signal between the aortic wall and the visceral pleura. The distance between the esophageal probe and the aortic wall was the most accurate sign because it could be easily obtained; the threshold value for this distance was 3 mm. TEE appears to be an accurate method to diagnose traumatic mediastinal hematoma.
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This was a prospective study of 52 patients that were extubated in our medical intensive care unit. Rapid shallow breathing, represented by a ratio of frequency to tidal volume (f/VT) of more than 105, was evaluated either on continuous positive airway pressure or pressure support prior to extubation as a marker of extubation outcome. Twelve out of 13 patients (92 percent) with rapid shallow breathing (f/VT ratio > 105) were successfully extubated. ⋯ A measured f/VT ratio of less than 105 had a sensitivity and specificity of 72 and 11 percent, respectively, for extubation success. Patients who had unsuccessful outcomes were ventilated for a significantly more prolonged period (9.6 +/- 6.8 d vs 4.6 +/- 3.9 d, unpaired t test, p = 0.004). We conclude that the presence of rapid shallow breathing during a weaning trial with the patient on partial ventilatory support does not necessarily preclude successful extubation.