A prospective, crossover, physiologic study was performed in 10 patients with acute lung injury to assess the respective short-term effects of noninvasive pressure-support ventilation and continuous positive airway pressure. We measured breathing pattern, neuromuscular drive, inspiratory muscle effort, arterial blood gases, and dyspnea while breathing with minimal support and the equipment for measurements, with two combinations of pressure-support ventilation above positive end-expiratory pressure (10–10 and 15–5 cm H2O), and with continuous positive airway pressure (10 cm H2O). Tidal volume was increased with pressure support, and not with continuous positive airway pressure. Neuromuscular drive and inspiratory muscle effort were lower with the two pressure-support ventilation levels than with other situations (p < 0.05). Dyspnea relief was significantly better with high-level pressure-support ventilation (15–5 cm H2O; p < 0.001). Oxygenation improved when 10 cm H2O positive end-expiratory pressure was applied, alone or in combination. We conclude that, in patients with acute lung injury (1) noninvasive pressure-support ventilation combined with positive end-expiratory pressure is needed to reduce inspiratory muscle effort; (2) continuous positive airway pressure, in this setting, improves oxygenation but fails to unload the respiratory muscles; and (3) pressure-support levels of 10 and 15 cm H2O provide similar unloading but differ in their effects on dyspnea.

Intubation and extubation of ventilated patients are not risk-free procedures in the intensive care unit (ICU) and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in emergency situations for patients with an unstable cardiovascular or respiratory system. Under these circumstances, it is a high-risk procedure with life-threatening complications (20–50%). Moreover, technical problems can also give rise to complications and several new techniques, such as videolaryngoscopy, have been developed recently. Another risk period is extubation, which fails in approximately 10% of cases and is associated with a poor prognosis. A better understanding of the cause of failure is essential to improve success procedure. In constructing these guidelines, the SFAR/SRLF experts have made use of new data on intubation and extubation in the ICU from the last decade to update existing procedures, incorporate more recent advances and propose algorithms.

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/−) and 6 a low level of proof (Grade 2+/−). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

OBJECTIVE: To evaluate the clinical relevance of the weaning from mechanical ventilation classification system derived from the 2005 international consensus conference, in patients who receive mechanical ventilation for more than 48 hours, and evaluate its correlation with prognosis. METHODS: We conducted a retrospective cohort study in a 12-bed intensive care unit (ICU) in a teaching hospital. We included patients who required > 48 hours of mechanical ventilation and who passed a spontaneous breathing trial (SBT). Weaning and sedation were monitored according to standardized protocol-directed procedures. We collected data on physiological characteristics, mechanical ventilation duration, ICU and hospital stay, and mortality from the medical records database. We assessed one-year mortality with a prospective, standardized method. Multivariate logistic regression was performed to evaluate the association between weaning categories and outcome. RESULTS: We included 329 ventilation episodes, in which 115 patients passed at least one SBT. Thirty-four patients (30%) succeeded in their first SBT (simple weaning group), 47 patients (40%) succeeded in their 2nd or 3rd SBT or in less than 7 days of weaning (the difficult weaning group), and 34 patients (30%) required more than 3 SBTs or more than 7 days of weaning (the prolonged weaning group). There were significant differences in ICU and hospital mortality between the simple, difficult, and prolonged-weaning groups. Prolonged weaning was an independent risk factor for longer ICU stay (odds ratio 15.11, 95% CI 1.61–141.91, P = .01) and hospital mortality (odds ratio 3.66, 95% CI 0.99–13.51). However, the weaning process did not impact one-year mortality (odds ratio 2.61, 95% CI 0.82–8.35). CONCLUSIONS: The new weaning classification system is clinically relevant and correlates to ICU and hospital mortality, but not to one-year mortality.