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Although the Berlin definition of the acute respiratory distress syndrome (ARDS) is generally recognized, the differentiation from other diseases with severe gas exchange disturbances is often difficult in clinical practice. In particular, the assessment of radiological findings and identification of primary noncardiogenic lung edema pose problems. In ARDS typical inflammatory processes can be found with involvement of activated neutrophilic granulocytes. Anti-inflammatory treatment strategies were unsuccessful. Lung protective ventilation strategies and prone positioning are the only evidence-based treatment options. Identifying ARDS phenotypes according to the etiology or disease progression can possibly provide a targeted individualized treatment option. The control of various biomarkers for assessment and treatment is the main focus of scientific interest. The results of appropriate studies remain to be seen. [ABSTRACT FROM AUTHOR]

Treatment of patients suffering from acute lung injury is a challenge for the treating physician. In recent years ventilation of patients with acute hypoxic lung injury has changed fundamentally. Besides the use of low tidal volumes, the most beneficial setting of positive end-expiratory pressure (PEEP) has been in the focus of researchers. The findings allow adaption of treatment to milder forms of acute lung injury and severe forms. Additionally computed tomography techniques to assess the pulmonary situation and recruitment potential as well as bed-side techniques to adjust PEEP on the ward have been modified and improved. This review gives an outline of recent developments in PEEP adjustment for patients suffering from acute hypoxic and hypercapnic lung injury and explains the fundamental pathophysiology necessary as a basis for correct treatment. [ABSTRACT FROM AUTHOR]

Treatment of patients suffering from acute lung injury is a challenge for the treating physician. In recent years ventilation of patients with acute hypoxic lung injury has changed fundamentally. Besides the use of low tidal volumes, the most beneficial setting of positive end-expiratory pressure (PEEP) has been in the focus of researchers. The findings allow adaption of treatment to milder forms of acute lung injury and severe forms. Additionally computed tomography techniques to assess the pulmonary situation and recruitment potential as well as bed-side techniques to adjust PEEP on the ward have been modified and improved. This review gives an outline of recent developments in PEEP adjustment for patients suffering from acute hypoxic and hypercapnic lung injury and explains the fundamental pathophysiology necessary as a basis for correct treatment. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that ventilation with 3 mL/kg tidal volume combined with extracorporeal CO2 removal by arteriovenous interventional lung assist reduces ventilator-associated organ injury in experimental acute lung injury when compared with ventilation with 6 mL/kg tidal volume without interventional lung assist.Design: Prospective, randomized, controlled trial.Setting: A university research laboratory.Subjects: A total of 14 pigs weighing 46 +/- 4 kg (mean +/- sd).Interventions: Acute lung injury was induced by repeated lung lavages until Pao2 was <100 mm Hg, with Fio2 of 1.0 and positive end-expiratory pressure of 5 cm H2O, for 1 hr without additional lavages. Animals were randomized to an interventional group with a tidal volume of 3 mL/kg with interventional lung assist (n = 7) or to a control group with a tidal volume of 6 mL/kg without interventional lung assist (n = 7) for 24 hrs. Organ function in vivo was determined by laboratory analyses, including calculations of pulmonary ventilation/perfusion distribution. Histologic assessment of organ injury was performed post mortem after 24 hrs.Measurements and Main Results: In both groups, gas exchange improved in the course of the study (p < .05). However, in contrast to control animals, animals with lower tidal volumes and interventional lung assist had severe ventilation/perfusion mismatch, as indicated by increased perfusion to lung areas with a low ventilation/perfusion ratio (p < .05). Other variables of organ function in vivo and results of histologic examination post mortem did not reveal any statistical difference between groups.Conclusions: Combined ventilation with lower tidal volumes and extracorporeal CO2 removal as compared with traditional low tidal volumes without extracorporeal CO2 removal is not associated with differences in organ injury. Obviously, ventilation with tidal volumes of <6 mL/kg may cause pulmonary de-recruitment when positive end-expiratory pressure is not adequately increased. [ABSTRACT FROM AUTHOR]

Background: Repair of giant incisional hernias may lead to an increase in intra-abdominal pressure (IAP) and, sometimes, to abdominal compartment syndrome. Measurement of IAP using Kron's technique (Kron et al. in Ann Surg 199:28-30, 1984) is currently accepted as the gold standard, whereas Harrahill has described a simple measurement setup using urinary drainage manometry (Harrahill in J Emerg Nurs 24:465-466, 1998). The aim of this clinical trail was to evaluate the correlation, reproducibility and effectiveness of this device.Methods: A prospective cohort study was performed in 43 patients undergoing elective standard abdominal intervention with laparotomy. These patients remain under surveillance in the intensive care unit and require a urinary catheter because of the operation. We performed comparative measurements of IAP using both Korn's (IVM) and Harrahill's (UDM) technique.Results: Evaluating the correlation between the IVM and UDM techniques, we measured median IAPs of 9.8 +/- 4.1 mmHg (2.9-19.9 mmHg) and 10.0 +/- 4.1 mmHg (min-max: 1.5-19.9 mmHg), respectively. Pearson's coefficient of correlation was r = 0.97. The average of difference between UDM and IVM was -0.2 +/- 0.9 mmHg with limits of agreement of -1.7 to 2.0 mmHg. Evaluating the reproducibility of Harrahill's technique, we found median IAPs of 10.4 +/- 2.1 mmHg (min-max: 2.9-19.1 mmHg) and 10.4 +/- 2.7 mmHg (3.7-19.9 mmHg), respectively, in 43 comparative measurements (Pearson's coefficient of correlation, r = 0.97. The average difference between both measurements was -0.1 +/- 1.1 mmHg with limits of agreement of -2.3 to 2.2 mmHg.Conclusions: We were able to demonstrate good correlation and high reproducibility of IAP measurement using Harrahill's technique compared to the gold standard Korn method. We consider this technique as a suitable method for quick and simple screening test for intra-abdominal hypertension, especially after repair of giant incisional hernias. [ABSTRACT FROM AUTHOR]

Background: In order to provide early achievement of practical experience during medical education, the medical faculty of the university Aachen has developed a new medical school curriculum which was offered in 2003 for the first time. In this curriculum anaesthesiology became a compulsory subject with practical training both in the operation theatre and in emergency medicine. Accordingly, a practical course in the field of intensive care medicine has also been designed with respect to the planned schedule and personnel resources. This course was evaluated by both students and teaching staff in a written, anonymous form as a quality control.Methods: A dedicated course was developed for medical students of the 8th and 9th semesters. In this course comprised of 6 students and lasting 1 week, practical training is provided by intensive care physicians and accompanied by theoretical lessons focusing on the definition, diagnosis, therapy and prophylaxis of sepsis, essentials of mechanical ventilation and patient presentation at the bedside during daily rounds. On the last day of training students were required to present patients by themselves thereby recapitulating the acquired knowledge. In the summer semester 2007 this intensive care training course was offered for the first time. All participating 83 students and 23 physicians involved in teaching evaluated the course with marks from 1 to 6 according to the standard German school grading system using an online questionnaire.Results: Students rated the course with 1.6+/-0.7 (mean +/- SD) for comprehensibility, with 1.6+/-0.7 for structural design, and with 1.7+/-0.7 for agreement between teachers. They graded their personal learning success with 1.7+/-0.7. With a cumulative mark of 1.7+/-0.6, the course was ranked as 1 of the top 3 courses of the medical faculty from the very beginning. The majority of the teaching staff (80%) appreciated the focus on few selected teaching subjects. However, comprehensibility, structural design, agreement between teachers and personal learning success were graded one mark worse than by the students.Conclusions: According to the results, efficiency and acceptance of intensive care training courses were high. Major criteria for the high grading were a limited number of participants, the focus on few subjects, and a clear structural design. However, according to several personal notes from the students, simulation-based sessions and written teaching material might further improve success of this course. [ABSTRACT FROM AUTHOR]

Repair of giant incisional hernias may lead to an increase in intra-abdominal pressure (IAP) and, sometimes, to abdominal compartment syndrome. Measurement of IAP using Kron’s technique (Kron et al. in Ann Surg 199:28–30, ) is currently accepted as the gold standard, whereas Harrahill has described a simple measurement setup using urinary drainage manometry (Harrahill in J Emerg Nurs 24:465–466, ). The aim of this clinical trail was to evaluate the correlation, reproducibility and effectiveness of this device. A prospective cohort study was performed in 43 patients undergoing elective standard abdominal intervention with laparotomy. These patients remain under surveillance in the intensive care unit and require a urinary catheter because of the operation. We performed comparative measurements of IAP using both Korn’s (IVM) and Harrahill’s (UDM) technique. Evaluating the correlation between the IVM and UDM techniques, we measured median IAPs of 9.8 ± 4.1 mmHg (2.9–19.9 mmHg) and 10.0 ± 4.1 mmHg (min–max: 1.5–19.9 mmHg), respectively. Pearson’s coefficient of correlation was r = 0.97. The average of difference between UDM and IVM was −0.2 ± 0.9 mmHg with limits of agreement of −1.7 to 2.0 mmHg. Evaluating the reproducibility of Harrahill’s technique, we found median IAPs of 10.4 ± 2.1 mmHg (min–max: 2.9–19.1 mmHg) and 10.4 ± 2.7 mmHg (3.7–19.9 mmHg), respectively, in 43 comparative measurements (Pearson’s coefficient of correlation, r = 0.97. The average difference between both measurements was −0.1 ± 1.1 mmHg with limits of agreement of −2.3 to 2.2 mmHg. We were able to demonstrate good correlation and high reproducibility of IAP measurement using Harrahill’s technique compared to the gold standard Korn method. We consider this technique as a suitable method for quick and simple screening test for intra-abdominal hypertension, especially after repair of giant incisional hernias. [ABSTRACT FROM AUTHOR]

In order to provide early achievement of practical experience during medical education, the medical faculty of the university Aachen has developed a new medical school curriculum which was offered in 2003 for the first time. In this curriculum anaesthesiology became a compulsory subject with practical training both in the operation theatre and in emergency medicine. Accordingly, a practical course in the field of intensive care medicine has also been designed with respect to the planned schedule and personnel resources. This course was evaluated by both students and teaching staff in a written, anonymous form as a quality control. A dedicated course was developed for medical students of the 8th and 9th semesters. In this course comprised of 6 students and lasting 1 week, practical training is provided by intensive care physicians and accompanied by theoretical lessons focusing on the definition, diagnosis, therapy and prophylaxis of sepsis, essentials of mechanical ventilation and patient presentation at the bedside during daily rounds. On the last day of training students were required to present patients by themselves thereby recapitulating the acquired knowledge. In the summer semester 2007 this intensive care training course was offered for the first time. All participating 83 students and 23 physicians involved in teaching evaluated the course with marks from 1 to 6 according to the standard German school grading system using an online questionnaire. Students rated the course with 1.6±0.7 (mean ± SD) for comprehensibility, with 1.6±0.7 for structural design, and with 1.7±0.7 for agreement between teachers. They graded their personal learning success with 1.7±0.7. With a cumulative mark of 1.7±0.6, the course was ranked as 1 of the top 3 courses of the medical faculty from the very beginning. The majority of the teaching staff (80%) appreciated the focus on few selected teaching subjects. However, comprehensibility, structural design, agreement between teachers and personal learning success were graded one mark worse than by the students. According to the results, efficiency and acceptance of intensive care training courses were high. Major criteria for the high grading were a limited number of participants, the focus on few subjects, and a clear structural design. However, according to several personal notes from the students, simulation-based sessions and written teaching material might further improve success of this course. [ABSTRACT FROM AUTHOR]

Objective: The early phase of acute respiratory distress syndrome (ARDS) is characterized by impaired respiratory mechanics, ventilation-perfusion mismatch, and severe hypoxemia. Partial ventilatory support can effectively unload the respiratory workload and improve pulmonary gas exchange with less hemodynamic compromise. The partial ventilatory support mode most indicated in early phases of ARDS has not been determined. This study compares the effects of assisted ventilatory techniques on breathing pattern, gas exchange, hemodynamic function, and respiratory effort with those of controlled mechanical ventilation in similarly sedated subjects. Design: Prospectively randomized crossover animal study. Setting: Animal research laboratory. Subjects: Eleven anesthetized and mechanically ventilated pigs. Interventions: Acute lung injury was induced by lung lavage. Pressure-controlled ventilation (PCV), pressure-controlled assisted ventilation (P-ACV), bilevel positive airway pressure (BIPAP), and pressure support ventilation (PSV) with equal airway pressures and sedation were applied in random order. Measurements and Main Results: Gas exchange, respiratory effort, and hemodynamic function were measured, and ventilation-perfusion distributions were calculated by multiple inert-gas-elimination techniques. The results revealed that partial ventilatory support was superior to PCV in maintaining adequate oxygenation and hemodynamic function with reduced sedation. The effects of P-ACV, BIPAP, and PSV were comparable with respect to gas exchange and hemodynamic function, except for a more pronounced reduction in shunt during BIPAP. P-ACV and PSV were superior to BIPAP to reduce respiratory drive and work of breathing. PSV affected the pattern of breathing and deadspace to a greater degree than did P-ACV. Conclusions: In acute lung injury, P-ACV preserves oxygenation and hemodynamic function with less respiratory effort compared with BIPAP and reduces the need for sedation compared with PCV. [ABSTRACT FROM AUTHOR]

Background: Partial liquid ventilation, positive end-expiratory pressure (PEEP) and inhaled nitric oxide (NO) can improve ventilation/perfusion mismatch in acute lung injury (ALI). The aim of the present study was to compare gas exchange and hemodynamics in experimental ALI during gaseous and partial liquid ventilation at two different levels of PEEP, with and without the inhalation of nitric oxide.Methods: Seven pigs (24+/-2 kg BW) were surfactant-depleted by repeated lung lavage with saline. Gas exchange and hemodynamic parameters were assessed in all animals during gaseous and subsequent partial liquid ventilation at two levels of PEEP (5 and 15 cmH2O) and intermittent inhalation of 10 ppm NO.Results: Arterial oxygenation increased significantly with a simultaneous decrease in cardiac output when PEEP 15 cmH2O was applied during gaseous and partial liquid ventilation. All other hemodynamic parameters revealed no relevant changes. Inhalation of NO and instillation of perfluorocarbon had no additive effects on pulmonary gas exchange when compared to PEEP 15 cmH2O alone.Conclusion: In experimental lung injury, improvements in gas exchange are most distinct during mechanical ventilation with PEEP 15 cmH2O without significantly impairing hemodynamics. Partial liquid ventilation and inhaled NO did not cause an additive increase of PaO2. [ABSTRACT FROM AUTHOR]