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Chest X-ray of an ARDS victim who has developed multiple pneumothoraces secondary to a bronchopleural fistula.
Source publication
Pulmonary complications are prevalent in the critically ill neurological population. Respiratory failure, pneumonia, acute lung injury and the acute respiratory distress syndrome (ALI/ARDS), pulmonary edema, pulmonary contusions and pneumo/hemothorax, and pulmonary embolism are frequently encountered in the setting of severe brain injury. Direct br...
Contexts in source publication
Context 1
... traumatic pneumothorax, defined as the entry of air into the pleural space, occurs after both penetrating and nonpenetrating thoracic injuries. A simple pneumothorax occurs when there is no com- munication with the external environment or any shift of mediastinal structures (Figure 1), an open pneumothorax occurs when a communication or fistula exists between the pleural space and the environment (sucking wound), and finally, a tension pneumothorax occurs when escape of pleural air to the environment is prevented, and increasing intrapleural pressure leads to shift in mediastinal structures with associated hemodynamic compromise. Treatment of a small pneumothorax in a traumatized victim undergoing positive pressure ventilation requires the use of chest tubes, and a conservative approach with normobaric hyperoxia is not an alternative. ...Context 2
... of tension pneumothorax requires the use of immediate decompres- sion (needle thoracostomy) and/or rapid placement of a chest tube. The persistence of air leak and pneumothorax is indicative of a bronchopleural fistula and therefore requires immediate surgical revision with thoracotomy ( Figure 1). A hemothorax is the accumulation of blood in the pleural space and may be the cause of respiratory distress, pain, hypoxia, and circulatory arrest. ...Similar publications
Background:
Substance use is a potentially modifiable risk factor for suicidal behaviour. Little is known about the epidemiology of substance use among self-harm patients in South Africa. This study set out to collect epidemiological data about the prevalence, correlates, and patterns of medical service utilisation among self-harm patients who use...
Background:
Patients in vegetative (VS) and minimally conscious state (MCS) have different degrees of consciousness recovery but both display severe levels of disability.
Aim:
To describe and compare VS and MCS patients' functioning and disability according to ICF model (International Classification of Functioning, Disability and Health).
Desig...
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Hemorrhagic stroke is responsible for significant morbidity and mortality. Postpartum and pregnancy are risk period. Only urgent care in intensive care units may improve prognosis. We report the case of 22 years old's Morrocan, who presented to our department with an intense headache headset followed a few hours later by consciousness disorder. Cli...
Citations
... Intensive care unit (ICU) admissions almost certainly imply bed rest, especially in patients requiring invasive mechanical ventilation (IMV) [2]. Critical neurological patients are alarmingly predisposed to several harmful and pathophysiological events that are associated with ICU-acquired weakness (ICU-AW) and worsen the clinical prognosis, increasing morbidity, mortality, and hospital costs [3]. In this sense, a paradigm shift in approaching NCPs has emerged. ...
... The lowered level of consciousness and the consequent deficit in airway protection associated with secondary physiological brain damage and decreased mobility predispose these patients to pulmonary complications, making it necessary to use mechanical ventilation [3]. However, the use of this therapeutic resource has proven to be challenging because of the close relationship between the nervous and respiratory systems [1]. ...
Neurocritical patients (NCPs) in the intensive care unit (ICU) rapidly progress to respiratory and peripheral muscle dysfunctions, which significantly impact morbidity and death. Early mobilization in NCPs to decrease the incidence of ICU–acquired weakness has been showing rapid growth, although pertinent literature is still scarce. With this review, we summarize and discuss current concepts in early mobilization of critically ill patients within the context of neurologic pathology in NCPs. A narrative synthesis of literature was undertaken trying to answer the following questions: How do the respiratory and musculoskeletal systems in NCPs behave? Which metabolic biomarkers influence physiological responses in NCPs? Which considerations should be taken when prescribing exercises in neurocritically ill patients? The present review detected safety, feasibility, and beneficial response for early mobilization in NCPs, given successes in other critically ill populations and many smaller intervention trials in neurocritical care. However, precautions should be taken to elect the patient for early care, as well as monitoring signs that indicate interruption for intervention, as worse outcomes were associated with very early mobilization in acute stroke trials.
... This aggravates the symptoms of nervous system ischemia and hypoxia, creating a vicious cycle that further impacts the prognosis of patients (Mascia, 2009;Mrozek, Constantin, & Geeraerts, 2015;Mrozek, Gobin, Constantin, Fourcade, & Geeraerts, 2020). Impairment of lung function (respiratory failure, pulmonary edema, pendant pneumonia, septicemia, etc.) is the most common complication in many neurocritical patients during hospitalization (Hoesch et al., 2012;Lee & Rincon, 2012). For critically ill patients, lung diseases can aggravate brain injury, and respiratory failure and pendulous pneumonia are independent prognostic risk factors for brain injury patients (Chinese Neurosurgical Society of Chinese Medical Association & China Collaborative Group of Neurosurgical Intensive Care Management, 2020). ...
... Neurocritical patients have a high risk of suffering a lung injury during hospitalization, which would worsen their condition (Hoesch et al., 2012;Lee & Rincon, 2012;Mascia, 2009;Mrozek et al., 2015;Mrozek et al., 2020). This study aims to investigate a lung protection model for neurocritical patients, which involves collaboration among physicians, nurses, and healthcare professionals. ...
... The prevention strategy proposed in this study achieved good outcomes, as supported by other strategies developed elsewhere on the globe (Beuret et al., 2002;Corradi et al., 2018b;Lee & Rincon, 2012;Mrozek et al., 2015). The advantages of the strategy proposed here are that it requires no additional tools and equipment besides those already used in neurocritical care, and it favors the active participation of the whole neurocritical care team. ...
Background
Lung injury resulting from diffuse pulmonary interstitial and other lung-related complications is a significant contributor to poor prognosis and mortality in patients with critical neurological diseases. To enhance patient outcomes, it is essential to investigate a lung protection model that involves the collaboration of doctors, nurses, and other medical professionals.
Methods
Patients receiving different care styles were divided into two groups: routine care (RC) and lung function protection care (LFPC). The LFPC group included airway and posture management, sedation and analgesia management, positive end-expiratory pressure titration in ventilation management, and fluid volume management, among others. Statistical analysis methods, such as chi-square, were used to compare the incidence of acute lung injury (ALI), neurogenic pulmonary edema (NPE), ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS), and length of stay between the RC and LFPC groups.
Results
The RC group included 68 patients (33 males; 34–74 years of age). The LFPC group included 60 patients (29 males; 37–73 years of age). Compared with the RC group, the LFPC group had lower occurrence rates of ALI (20.0 % vs. 38.2 %, P = 0.024), NPE (8.3 % vs. 23.5 %, P = 0.021), VAP (8.3 % vs. 25.0 %, P = 0.013), and ARDS (1.7 % vs. 16.2 %, P = 0.015). The length of hospital stay was shorter in the LFPC group than in the RC group (11.3 ± 3.5 vs. 14.3 ± 4.4 days, P = 0.0001).
Conclusion
The physician-nurse integrated lung protection care model proved to be effective in improving outcomes, reducing complications, and shortening the hospital stay length for neurocritical patients.
... Neurosurgical outcomes, either congenital or acquired, frequently require intensive care pre and/or post procedures. Clinical outcomes vary and are determined by a variety of factors related to the mechanism of insult [1,2]. Consequently, a combination of depressed consciousness levels, inability to protect the airway, disruption of natural defence barriers, and decreased mobility is associated with prolonged mechanical ventilation and stay in the intensive care unit (ICU) [2][3][4]. ...
... Clinical outcomes vary and are determined by a variety of factors related to the mechanism of insult [1,2]. Consequently, a combination of depressed consciousness levels, inability to protect the airway, disruption of natural defence barriers, and decreased mobility is associated with prolonged mechanical ventilation and stay in the intensive care unit (ICU) [2][3][4]. ...
Introduction: Chest infections are a frequently encountered problem in patients admitted to the intensive care unit (ICU), more so in tracheostomised patients. This study aimed to audit the tracheostomy care practices in patients with neurosurgical pathologies in the ICU of Wellington Clinics Abuja, a tertiary neurosurgical hospital in Nigeria.
Methods: We conducted a closed-loop audit with mixed methods involving analysis of 24 patients who had tracheostomy within the first two weeks of neurosurgical pathology at a tertiary neurosurgical hospital and semi-structured interviews to determine tracheostomy care practices among the primary caregivers - nurses, intensivists, and doctors.
Results: Of the 161 ICU admissions in the first cycle, 22 patients received tracheostomy, 16 met the eligibility criteria. At re-audit (second cycle), eight of 40 patients met the criteria. All the patients received open suctioning through a dual cannula-cuffed tracheostomy tube and had independent portable suction units. In the baseline audit (first cycle), suction catheters were reused for 12-24 hours in each patient and were stored in varying combinations of normal saline and Savlon antiseptic (5 mg of cetrimide (0.5% w/w) and 1 mg of chlorhexidine digluconate (0.1% w/w)). The frequency, technique, and assessment of the need for airway suctioning were inconsistent among caregivers interviewed. All 16 patients had at least one episode of pneumonia, 10 patients had a second episode, and two patients had > two episodes. One mortality was recorded directly attributable to the complications of pneumonia. While in the re-audit, with adherence to recommendations, three patients suffered one episode of pneumonia and only one had a second episode. No mortality was recorded.
Conclusion: A standard practice guideline was necessary for tracheostomy care in our ICU. In low-resource settings, stated recommendations such as single-use suction catheters and improved hygienic practices can reduce rates of pneumonia in tracheostomised patients.
... The third is PEV-induced systemic inflammation, immune dysregulation, and intravascular coagulation. The lungs are the most common organ that develops secondary injury post TBI [87,88], usually manifesting as acute lung injury, acute respiratory distress syndrome, pneumonia, pleural effusion, pulmonary edema, and pulmonary thromboembolism [25,90]. Kerr et al. found that EVs carrying proinflammatory cytokines were released into the peripheral circulation after TBI in experimental mice, and these EVs were endocytosed by pulmonary cells including endothelial cells to trigger inflammasome activation and resultant lung injury [36,91]. ...
Traumatic brain injury (TBI) is a leading cause of injury-related disability and death around the world, but the clinical stratification, diagnosis, and treatment of complex TBI are limited. Due to their unique properties, extracellular vesicles (EVs) are emerging candidates for being biomarkers of traumatic brain injury as well as serving as potential therapeutic targets. However, the effects of different extracellular vesicle subtypes on the pathophysiology of traumatic brain injury are very different, or potentially even opposite. Before extracellular vesicles can be used as targets for TBI therapy, it is necessary to classify different extracellular vesicle subtypes according to their functions to clarify different strategies for EV-based TBI therapy. The purpose of this review is to discuss contradictory effects of different EV subtypes on TBI, and to propose treatment ideas based on different EV subtypes to maximize their benefits for the recovery of TBI patients. Video Abstract.
... Many patients with acute brain injury (ABI) require invasive mechanical ventilation (IMV) and admission to an intensive care unit (ICU). 1,2 Non-neurologic complications, including the acute respiratory distress syndrome (ARDS), [3][4][5][6] are an important source of additional morbidity and mortality in this population. ARDS occurs in 20% to 30% of patients with ABI, [7][8][9] whereas its incidence is 10% in mixed cohorts of critically ill patients admitted to the ICU. 10 Brain injury is thought to mediate susceptibility to ARDS through immune suppression, sympathetic activation, and release of pro-inflammatory cytokines following the initial neurologic insult. ...
... However, the association between ARDS and worse clinical outcomes has high face validity and is consistent with existing findings, including in patients with and without ABI. 6,19,38,39 For some outcomes in this analysis, the associations followed an expected gradient, in which effect sizes strengthened as ARDS severity worsened. Findings from our sensitivity analysis suggested that residual confounding was unlikely to negate our study's conclusions. ...
Background: Acute respiratory distress syndrome (ARDS) is an important pulmonary complication in brain-injured patients receiving invasive mechanical ventilation (IMV). We aimed to evaluate the incidence and association between ARDS and clinical outcomes in patients with different forms of acute brain injury requiring IMV in the intensive care unit (ICU). Methods: This was a preplanned secondary analysis of a prospective, multicenter, international cohort study (NCT03400904). We included brain-injured patients receiving IMV for ≥ 24 h. ARDS was the main exposure of interest and was identified during index ICU admission using the Berlin definition. We examined the incidence and adjusted association of ARDS with ICU mortality, ICU length of stay, duration of IMV, and extubation failure. Outcomes were evaluated using mixed-effect logistic regression and cause-specific Cox proportional hazards models. Results: 1492 patients from 67 hospitals and 16 countries were included in the analysis, of whom 137 individuals developed ARDS (9.2% of overall cohort). Across countries, the median ARDS incidence was 5.1% (interquartile range [IQR] 0-10; range 0-27.3). ARDS was associated with increased ICU mortality (adjusted odds ratio (OR) 2.66; 95% confidence interval [CI], 1.29-5.48), longer ICU length of stay (adjusted hazard ratio [HR] 0.59; 95% CI, 0.48-0.73), and longer duration of IMV (adjusted HR 0.54; 95% CI, 0.44-0.67). The association between ARDS and extubation failure approached statistical significance (adjusted HR 1.48; 95% CI 0.99-2.21). Higher ARDS severity was associated with incrementally longer ICU length of stay and longer cumulative duration of IMV. Findings remained robust in a sensitivity analysis evaluating the magnitude of unmeasured confounding. Conclusions: In this cohort of acutely brain-injured patients, the incidence of ARDS was similar to that reported in other mixed cohorts of critically ill patients. Development of ARDS was associated with worse outcomes.
... This raises the question of a possible association between impairment of cerebral autoregulation and lung injury. It is known that severe TBI may induce lung distress and edema, such as neurogenic pulmonary edema [5,34]. Consistently, our results showed that there was a significant positive association between outcome and CP-Popt-target management. ...
Introduction
Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications.
Aim of the study
We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome.
Methods and results
Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO 2 /FiO 2 ) was 305±88 and driving pressure 15.9±3.5cmH 2 O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found.
Conclusion
Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.
... Pneumonia is one of the most common respiratory complications in stroke patients, affecting 5 to 9% of patients (6,7), and is much commoner in patients admitted to neuro-ICUs, which are ICUs devoted to the care of patients with immediately life-threatening neurological problems (incidence, 13-33%) (8). Due to the long time spent in the prone position and the risk of inhaling stomach contents that comes with it, a large number of people (up to 60%) with serious brain injuries develop pneumonia (9). ...
Pneumonia is one of the most prevalent infections in the intensive care unit (ICU), where pneumonia may occur during hospitalization in the ICU as a complication. ICU patients with central nervous system (CNS) injuries are not an exception, and they may even be more susceptible to infections such as pneumonia due to issues such as swallowing difficulties, the requirement for mechanical ventilation, and extended hospital stay. Numerous common CNS injuries, such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage, can prolong hospital stay and increase the risk of pneumonia. Multidrug‑resistant (MDR) microorganisms are a common and significant concern, with increased mortality in nosocomial pneumonia. However, research on pneumonia due to MDR pathogens in patients with CNS injuries is limited. The aim of the present review was to provide the current evidence regarding pneumonia due to MDR pathogens in patients with CNS injuries. The prevalence of pneumonia due to MDR pathogens in CNS injuries differs among different settings, types of CNS injuries, geographical areas, and time periods in which the studies were performed. Specific risk factors for the emergence of pneumonia due to MDR pathogens have been identified in ICUs and neurological rehabilitation units. Antimicrobial resistance is currently a global issue, although using preventive measures, early diagnosis, and close monitoring of MDR strains may lessen its impact. Since there is a lack of information on these topics, more multicenter prospective studies are required to offer insights into the clinical features and outcomes of these patients.
... Remarkable brain and brainstem demyelination influence motor pathways, especially those that innervate limbs, which lead to mobility weakness or impairment. Multiple sclerosis is a neuro-inflammatory and demyelinated disease associated with lesions throughout the CNS, which depending on the involved brain area incurs in some disabilities [288,289]. Pulmonary dysfunction manifested in MS primarily include impaired respiratory muscles that result in pulmonary weakness and cough. Expiratory muscles are probably more at risk to suffer impairment. ...
Coronavirus disease-2019 (COVID-19) is associated with cytokine storm and is characterized by acute respiratory distress syndrome (ARDS) and pneumonia problems. The respiratory system is a place of inappropriate activation of the immune system in people with multiple sclerosis (MS), and this may cause damage to the lung and worsen both MS and infections.
The concerns for patients with multiple sclerosis are because of an enhance risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The MS patients pose challenges in this pandemic situation, because of the regulatory defect of autoreactivity of the immune system and neurological and respiratory tract symptoms. In this review, we first indicate respiratory issues associated with both diseases. Then, the main mechanisms inducing lung damages and also impairing the respiratory muscles in individuals with both diseases is discussed. At the end, the leading role of physical exercise on mitigating respiratory issues inducing mechanisms is meticulously evaluated.
... Many secondary lesions in patients with TBI occur in a medium-long term period, and the appearance of brain and pulmonary complications is highly prevalent. Direct brain injury and altered levels of consciousness decrease the protection of the airways and alter the natural defense barrier, which adds to reduced mobility and multiple pathophysiological deficits inherent to the injury [3] and triggers several lung injuries, like neurogenic pulmonary edema (NPE), acute respiratory distress syndrome (ARDS), and ventilation-associated pneumonia (VAP). In the same way, lung injuries can affect the brain due to alterations in pulmonary physiology having repercussions at the systemic level, leading to neurological disorders which can be triggered mainly by hypoxia and intracranial hypertension [3,4]. ...
... Direct brain injury and altered levels of consciousness decrease the protection of the airways and alter the natural defense barrier, which adds to reduced mobility and multiple pathophysiological deficits inherent to the injury [3] and triggers several lung injuries, like neurogenic pulmonary edema (NPE), acute respiratory distress syndrome (ARDS), and ventilation-associated pneumonia (VAP). In the same way, lung injuries can affect the brain due to alterations in pulmonary physiology having repercussions at the systemic level, leading to neurological disorders which can be triggered mainly by hypoxia and intracranial hypertension [3,4]. The brain and lungs share fundamental connections that are compromised in patients with TBI. ...
The brain-lung interaction can seriously affect patients with traumatic brain injury, triggering a vicious cycle that worsens patient prognosis. Although the mechanisms of the interaction are not fully elucidated, several hypotheses, notably the "blast injury" theory or "double hit" model, have been proposed and constitute the basis of its development and progression. The brain and lungs strongly interact via complex pathways from the brain to the lungs but also from the lungs to the brain. The main pulmonary disorders that occur after brain injuries are neurogenic pulmonary edema, acute respiratory distress syndrome, and ventilator-associated pneumonia, and the principal brain disorders after lung injuries include brain hypoxia and intracranial hypertension. All of these conditions are key considerations for management therapies after traumatic brain injury and need exceptional case-by-case monitoring to avoid neurological or pulmonary complications. This review aims to describe the history, pathophysiology, risk factors, characteristics, and complications of brain-lung and lung-brain interactions and the impact of different old and recent modalities of treatment in the context of traumatic brain injury.
... The finding suggests that the patients in the neurosurgical/surgical non-ICUs, and those who have an alteration of consciousness or brain surgery are at greatest risk of VAP. We hypothesize that the increased risk of VAP is due to decreased bowel motility and subsequent colonization with pathogenic bacteria [14], placement in a supine position, feeding through an oro-or nasogastric tube [15], and intubation in emergency conditions outside the operating room [16]. Therefore, the hospital should emphasize specific strategies to prevent VAP in neurosurgical/surgical non-ICUs. ...
Introduction:
Ventilator-associated pneumonia patients are treated in non-intensive care units because of a shortage of intensive care unit beds in Thailand. Our objective was to assess whether the type of unit and medications prescribed to the patient were associated with ventilator‑associated pneumonia and multidrug resistant ventilator‑associated pneumonia.
Methodology:
A matched case-control study nested in a prospective cohort of mechanical ventilation adult patients in a medical-surgical intensive care unit and five non-intensive care units from March 1 through October 31, 2013. The controls were randomly selected 1:1 with cases and matched based on duration and start date of mechanical ventilation.
Results:
248 ventilator-associated pneumonia and control patients were analyzed. The most common bacteria were multidrug resistant Acinetobacter baumannii (82.4%). Compared with patients in the intensive care unit, those in the neurosurgical/surgical non-intensive care units were at higher risk (p = 0.278). Proton pump inhibitor was a risk factor (p = 0.011), but antibiotic was a protective factor (p = 0.054). Broad spectrum antibiotic was a risk factor (p < 0.001) for multidrug resistant ventilator-associated pneumonia.
Conclusions:
Post-surgical and neurosurgical patients treated in non-intensive care unit settings were at the highest risk of ventilator-associated pneumonia. Our findings suggest that alternative using proton pump inhibitors should be considered based on the risk-benefit of using this medication. In addition, careful stewardship of antibiotic use should be warranted to prevent multidrug resistant ventilator-associated pneumonia.
