Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are conditions associated with an estimated mortality of 40–50%. The use of inhaled vasodilators can help to improve oxygenation without hemodynamic effects. This article reviews relevant studies addressing the safety and efficacy of inhaled nitric oxide (iNO) and aerosolized epoprostenol (aEPO) in the treatment of life-threatening hypoxemia associated with ARDS and ALI. In addition, the article also provides a practicable guide to the clinical application of these therapies. Nine prospective randomized controlled trials were included for iNO reporting on changes in oxygenation or clinical outcomes. Seven reports of aEPO were examined for changes in oxygenation. Based on currently available data, the use of either iNO or aEPO is safe to use in patients with ALI or ARDS to transiently improve oxygenation. No differences have been observed in survival, ventilator-free days, or attenuation in disease severity. Further studies with consistent end points using standard delivery devices and standard modes of mechanical ventilation are needed to determine the overall benefit with iNO or aEPO.

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OBJECTIVES Therapeutic hypothermia improves survival in patients following cardiac arrest; yet the impact of body mass index(BMI) on survival is lesser known. We hypothesized that non-obese patients would have greater survival post therapeutic hypothermia than obese patients. METHODS We retrospectively evaluated 164 patients who underwent therapeutic hypothermia following resuscitation for cardiac arrest from 1/2012-9/2014. Logistic regression analysis was used to assess for survival based upon BMI and comorbidities(odds ratio[OR], 95% confidence interval[CI]). RESULTS Forty-one percent of patients were obese. Obese patients presented less frequently with ventricular fibrillation(p=0.046) but had similar rates of pulseless electrical activity(p=0.479), and ventricular tachycardia(p=0.262) as non-obese patients. In multivariable analysis, BMI <30kg/m2, hypertension, presence of pacemaker/implantable cardioverter defibrillator(PM/ICD), high glomerular filtration rate(GFR), and low neuron-specific enolase(NSE) were all associated with increased survival post therapeutic hypothermia respectively: 0.36(0.16-0.78), 0.28(0.12-0.66), 0.23(0.08-0.62), 0.25(0.11-0.56), 0.37(0.14-0.96). Other comorbidities demonstrated no association with survival. CONCLUSIONS BMI ≥30kg/m2 compared to BMI <30kg/m2 was a significant risk factor for mortality post therapeutic hypothermia protocol. Absence of history of hypertension, lack of PM/ICD, high NSE, and renal disease had greater associations with death. Larger studies will be needed to validate these findings.

With growing experience, the indications for salvage extracorporeal membrane oxygenation continue to expand. We describe a successful application of extracorporeal support in a polytrauma patient presenting with profound hypothermia, respiratory failure, and whom was later found to have an intracranial hemorrhage. We advocate the role of salvage therapy even in patients with complex pathophysiology despite perceived relative or absolute contraindications to extracorporeal support.

BackgroundIn 2010, the incidence of prolonged mechanical ventilation (> 24 hours) after isolated coronary artery bypass graft (CABG) surgery was 26.9% at the study site, The Ohio State University Wexner Medical Center, compared with the national like-hospital rate of 10.9%. Objectives To use the principles of lean management to reduce the incidence of prolonged mechanical ventilation and to assess the sustainability of that reduction over time. Methods A multidisciplinary prolonged ventilation task force conducted a gap analysis leading to 3 interventions: (1) a standardized extubation protocol, (2) dry erase boards in patients' rooms to facilitate team communication, and (3) edits of the postoperative order set within the electronic health record. Outcomes of mechanical ventilation in CABG patients before and after the interventions are compared. Results All target outcomes changed significantly after the interventions, including a reduction in the median hours of initial mechanical ventilation (from 11.4 hours to 6.9 hours, P < .001). The percentage of patients reintubated did not increase (a decrease from 11.8% to 3.5% was not significant, P = .08). The rate of prolonged ventilation decreased from 29.4% to 8.6% (P = .004), and this reduction was sustained for 4 years after the interventions. Conclusions Success factors included the multidisciplinary task force and continual protocol reeducation among front-line staff.