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Delorme M, Leroux K, Boussaid G, Lebret M, Prigent H, Leotard A, Louis B, Lofaso F. Protective Recommendations for Non-invasive Ventilation During COVID-19 Pandemic: A Bench Evaluation of the Effects of Instrumental Dead Space on Alveolar Ventilation. Arch Bronconeumol 2021; 57:28-33. [PMID: 34629640 PMCID: PMC8046339 DOI: 10.1016/j.arbres.2021.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/02/2021] [Indexed: 12/14/2022]
Abstract
Introduction With the current COVID-19 pandemic, concerns have raised regarding the risk for NIV to promote airborne transmission. In case of hospital admission, continuation of therapy in patients undergoing chronic NIV is necessary and several protective circuit configurations have been recommended to reduce the risk of aerosol dissemination. However, all these configurations increase instrumental dead space. We therefore designed this study to evaluate their effects on the tidal volume (VTE) required to preserve stable end-tidal CO2 partial pressure (PETCO2) with constant respiratory rate. Methods A bench consisting of a test lung connected to an adult-sized mannequin head was set up. The model was ventilated through usual domiciliary configuration (single limb circuit with facial vented mask) which was used as reference. Then, five different circuit configurations including non-vented facial mask with viral/bacterial filter, modification of leak position, and change from single to double-limb circuit were evaluated. For each configuration, pressure support (PS) was gradually increased to reach reference PETCO2. Resulting VTE was recorded as primary outcome. Results Reference PETCO2 was 38(0) mmHg, with a PS set at 10 cmH2O, resulting in a VTE of 432(2) mL. Compared to reference, all the configurations evaluated required substantial increase in VTE to preserve alveolar ventilation, ranging from +79(2) to +216(1) mL. Conclusions Modifications of NIV configurations in the context of COVID-19 pandemic result in substantial increase of instrumental dead space. Re-evaluation of treatment efficiency and settings is crucial whenever protective measures influencing NIV equipment are considered.
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Affiliation(s)
- Mathieu Delorme
- Université Paris-Saclay, UVSQ, ERPHAN, 78000 Versailles, France.
| | | | - Ghilas Boussaid
- Université Paris-Saclay, UVSQ, ERPHAN, 78000 Versailles, France
| | - Marius Lebret
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec, QC, Canada
| | - Helene Prigent
- Service de Physiologie - Explorations Fonctionnelles, Unité des Pathologies du Sommeil, AP-HP, Hôpital Raymond Poincaré, 92380 Garches, France; Université Paris-Saclay, UVSQ, INSERM U1179, Equipe 3, 78000 Versailles, France
| | - Antoine Leotard
- Service de Physiologie - Explorations Fonctionnelles, Unité des Pathologies du Sommeil, AP-HP, Hôpital Raymond Poincaré, 92380 Garches, France; Université Paris-Saclay, UVSQ, INSERM U1179, Equipe 3, 78000 Versailles, France
| | - Bruno Louis
- INSERM, U955, Université Paris Est Créteil, Faculté de Médecine, CNRS ERL 7000, 94010 Créteil, France
| | - Frédéric Lofaso
- Université Paris-Saclay, UVSQ, ERPHAN, 78000 Versailles, France; Service de Physiologie - Explorations Fonctionnelles, Unité des Pathologies du Sommeil, AP-HP, Hôpital Raymond Poincaré, 92380 Garches, France
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Suh ES, Pompilio P, Mandal S, Hill P, Kaltsakas G, Murphy PB, Romano R, Moxham J, Dellaca R, Hart N. Autotitrating external positive end-expiratory airway pressure to abolish expiratory flow limitation during tidal breathing in patients with severe COPD: a physiological study. Eur Respir J 2020; 56:13993003.02234-2019. [DOI: 10.1183/13993003.02234-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/01/2020] [Indexed: 11/05/2022]
Abstract
BackgroundThe optimal noninvasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFLT) and minimise intrinsic positive end-expiratory pressure (PEEPi) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFLT, would minimise PEEPi, work of breathing and neural respiratory drive (NRD) in patients with severe COPD.MethodsPatients with COPD with chronic respiratory failure underwent auto-titration of EPAP using a FOT-based algorithm that detected EFLT. Once optimal EPAP was identified, manual titration was performed to assess NRD (using diaphragm and parasternal intercostal muscle electromyography, EMGdi and EMGpara, respectively), transdiaphragmatic inspiratory pressure swings (ΔPdi), transdiaphragmatic pressure–time product (PTPdi) and PEEPi, between EPAP levels 2 cmH2O below to 3 cmH2O above optimal EPAP.ResultsOf 10 patients enrolled (age 65±6 years; male 60%; body mass index 27.6±7.2 kg.m−2; forced expiratory volume in 1 s 28.4±8.3% predicted), eight had EFLT, and optimal EPAP was 9 (range 4–13) cmH2O. NRD was reduced from baseline EPAP at 1 cmH2O below optimal EPAP on EMGdi and at optimal EPAP on EMGpara. In addition, at optimal EPAP, PEEPi (0.80±1.27 cmH2O versus 1.95± 1.70 cmH2O; p<0.05) was reduced compared with baseline. PTPdi (10.3±7.8 cmH2O·s−1versus 16.8±8.8 cmH2O·s−1; p<0.05) and ΔPdi (12.4±7.8 cmH2O versus 18.2±5.1 cmH2O; p<0.05) were reduced at optimal EPAP+1 cmH2O compared with baseline.ConclusionAutotitration of EPAP, using a FOT-based algorithm to abolish EFLT, minimises transdiaphragmatic pressure swings and NRD in patients with COPD and chronic respiratory failure.
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Martinez-García MA, Villa C, Dobarganes Y, Girón R, Maíz L, García-Clemente M, Sibila O, Golpe R, Rodríguez J, Barreiro E, Rodriguez JL, Menéndez R, Prados C, de la Rosa D, Olveira C. RIBRON: The spanish Online Bronchiectasis Registry. Characterization of the First 1912 Patients. Arch Bronconeumol 2020; 57:28-35. [PMID: 32081438 DOI: 10.1016/j.arbres.2019.12.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/15/2019] [Accepted: 12/15/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The SEPAR Spanish Bronchiectasis Registry (RIBRON) began as a platform for the collection of longitudinal data on patients with this disease. The objective of this study is to describe its operation and to analyze the characteristics of bronchiectasis patients according to sex. METHODS A total of 1912 adult patients diagnosed with bronchiectasis in 43 centers were included between February 2015 and 2019. All patients had complete data consisting of at least 79 basic required variables, controlled by an external audit. RESULTS Mean age was 67.6 (15.2) years; 63.9% were women. The most common symptom was productive cough (78.3%) which was mucopurulent-purulent in 45.9% of cases. The most common etiology was post-infectious (40.4%), while 18.5% were idiopathic. Pseudomonas aeruginosa was the most frequently isolated microorganism (40.4%), of which 25.6% were associated with chronic infection. The annual number of mild-to-moderate/severe exacerbations was 1.62 (1.9)/0.59 (1.3). Half of the patients (50%) presented with airflow obstruction (17% severe). The most frequent radiological localization was lower lobes. The average FACED/E-FACED/BSI values were 2.06 (1.7)/2.67 (2.2)/7.8 (4.5), respectively. Overall, 66.7% of patients were taking inhaled corticosteroids, 19.2% macrolides, and 19.5% inhaled antibiotics. Women presented a less severe profile than men in clinical and functional terms, and a similar infectious, radiological and therapeutic profile. CONCLUSIONS RIBRON represents an excellent map of the characteristics of bronchiectasis in our country. Two thirds of patients are women who presented lower disease severity as a specific characteristic.
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Affiliation(s)
| | - Carmen Villa
- Servicio de Neumología, Clínica Fuensanta, Madrid, España
| | | | - Rosa Girón
- Servicio de Neumología, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, España
| | - Luis Maíz
- Servicio de Neumología, Hospital Ramón y Cajal, Madrid, España
| | - Marta García-Clemente
- Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Oriol Sibila
- Servicio de Neumología, Hospital Clínico, Barcelona, España
| | - Rafael Golpe
- Servicio de Neumología, Hospital Lucus Augusti, Lugo, España
| | - Juan Rodríguez
- Servicio de Neumología, Hospital San Agustín, Avilés, Asturias, España
| | - Esther Barreiro
- Servicio de Neumología, Hospital del Mar-IMIM, UPF, CIBERES, Barcelona, España
| | | | - Rosario Menéndez
- Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | | | - David de la Rosa
- Servicio de Neumología, Hospital Santa Creu i Sant Pau, Barcelona, España
| | - Casilda Olveira
- Servicio de Neumología, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)/Universidad de Málaga, Málaga, España
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Clinical assessment of auto-positive end-expiratory pressure by diaphragmatic electrical activity during pressure support and neurally adjusted ventilatory assist. Anesthesiology 2014; 121:563-71. [PMID: 25050572 DOI: 10.1097/aln.0000000000000371] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Auto-positive end-expiratory pressure (auto-PEEP) may substantially increase the inspiratory effort during assisted mechanical ventilation. Purpose of this study was to assess whether the electrical activity of the diaphragm (EAdi) signal can be reliably used to estimate auto-PEEP in patients undergoing pressure support ventilation and neurally adjusted ventilatory assist (NAVA) and whether NAVA was beneficial in comparison with pressure support ventilation in patients affected by auto-PEEP. METHODS In 10 patients with a clinical suspicion of auto-PEEP, the authors simultaneously recorded EAdi, airway, esophageal pressure, and flow during pressure support and NAVA, whereas external PEEP was increased from 2 to 14 cm H2O. Tracings were analyzed to measure apparent "dynamic" auto-PEEP (decrease in esophageal pressure to generate inspiratory flow), auto-EAdi (EAdi value at the onset of inspiratory flow), and IDEAdi (inspiratory delay between the onset of EAdi and the inspiratory flow). RESULTS The pressure necessary to overcome auto-PEEP, auto-EAdi, and IDEAdi was significantly lower in NAVA as compared with pressure support ventilation, decreased with increase in external PEEP, although the effect of external PEEP was less pronounced in NAVA. Both auto-EAdi and IDEAdi were tightly correlated with auto-PEEP (r = 0.94 and r = 0.75, respectively). In the presence of auto-PEEP at lower external PEEP levels, NAVA was characterized by a characteristic shape of the airway pressure. CONCLUSIONS In patients with auto-PEEP, NAVA, compared with pressure support ventilation, led to a decrease in the pressure necessary to overcome auto-PEEP, which could be reliably monitored by the electrical activity of the diaphragm before inspiratory flow onset (auto-EAdi).
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Akoumianaki E, Prinianakis G, Kondili E, Malliotakis P, Georgopoulos D. Physiologic comparison of neurally adjusted ventilator assist, proportional assist and pressure support ventilation in critically ill patients. Respir Physiol Neurobiol 2014; 203:82-9. [PMID: 25169117 DOI: 10.1016/j.resp.2014.08.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/08/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED To compare, in a group of difficult to wean critically ill patients, the short-term effects of neurally adjusted ventilator assist (NAVA), proportional assist (PAV+) and pressure support (PSV) ventilation on patient-ventilator interaction. METHODS Seventeen patients were studied during NAVA, PAV+ and PSV with and without artificial increase in ventilator demands (dead space in 10 and chest load in 7 patients). Prior to challenge addition the level of assist in each of the three modes tested was adjusted to get the same level of patient's effort. RESULTS Compared to PSV, proportional modes favored tidal volume variability. Patient effort increase after dead space was comparable among the three modes. After chest load, patient effort increased significantly more with NAVA and PSV compared to PAV+. Triggering delay was significantly higher with PAV+. The linear correlation between tidal volume and inspiratory integral of transdiaphragmatic pressure (PTPdi) was weaker with NAVA than with PAV+ and PSV on account of a weaker inspiratory integral of the electrical activity of the diaphragm (∫EAdi)-PTPdi linear correlation during NAVA [median (interquartile range) of r(2), determination of coefficient, 16.2% (1.4-30.9%)]. CONCLUSION Compared to PSV, proportional modes favored tidal volume variability. The weak ∫EAdi-PTPdi linear relationship during NAVA and poor triggering function during PAV+ may limit the effectiveness of these modes to proportionally assist the inspiratory effort.
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Affiliation(s)
- Evangelia Akoumianaki
- Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - George Prinianakis
- Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Eumorfia Kondili
- Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Polychronis Malliotakis
- Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece.
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Abstract
Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) as a neural trigger to synchronize mechanical ventilatory breaths with the patient's neural respiratory drive. Using this signal enables the ventilator to proportionally support the patient's instantaneous drive on a breath-by-breath basis. Synchrony can be achieved even in the presence of significant air leaks, which make this an attractive choice for invasive and non-invasive ventilation of the neonate. This paper describes the Edi signal, neuroventilatory coupling, and patient-ventilator synchrony including the functional concept of NAVA. Safety features, NAVA terminology, and clinical application of NAVA to unload respiratory musculature are presented. The use of the Edi signal as a respiratory vital sign for conventional ventilation is discussed. The results of animal and adult studies are briefly summarized and detailed descriptions of all NAVA-related research in pediatric and neonatal patients are provided. Further studies are needed to determine whether NAVA will have significant impact on the overall outcomes of neonates.
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Gilstrap D, MacIntyre N. Patient-ventilator interactions. Implications for clinical management. Am J Respir Crit Care Med 2013; 188:1058-68. [PMID: 24070493 DOI: 10.1164/rccm.201212-2214ci] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Assisted/supported modes of mechanical ventilation offer significant advantages over controlled modes in terms of ventilator muscle function/recovery and patient comfort (and sedation needs). However, assisted/supported breaths must interact with patient demands during all three phases of breath delivery: trigger, target, and cycle. Synchronous interactions match ventilator support with patient demands; dyssynchronous interactions do not. Dyssynchrony imposes high pressure loads on ventilator muscles, promoting muscle overload/fatigue and increasing sedation needs. On current modes of ventilation there are a number of features that can monitor and enhance synchrony. These include adjustments of the trigger variable, the use of pressure versus fixed flow targeted breaths, and a number of manipulations of the cycle variable. Clinicians need to know how to use these modalities and monitor them properly, especially understanding airway pressure and flow graphics. Future strategies are emerging that have theoretical appeal but they await good clinical outcome studies before they become commonplace.
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Affiliation(s)
- Daniel Gilstrap
- 1 Department of Medicine, Duke University, Durham, North Carolina
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Abstract
OBJECTIVES To calculate an index (termed Pmusc/Eadi index) relating the pressure generated by the respiratory muscles (Pmusc) to the electrical activity of the diaphragm (Eadi), during assisted mechanical ventilation and to assess if the Pmusc/Eadi index is affected by the type and level of ventilator assistance. The Pmusc/Eadi index was also used to measure the patient's inspiratory effort from Eadi without esophageal pressure. DESIGN Crossover study. SETTING One general ICU. PATIENTS Ten patients undergoing assisted ventilation. INTERVENTION Pressure support and neurally adjusted ventilator assist delivered, each, at three levels of ventilatory assistance. MEASUREMENT AND MAIN RESULTS Airways flow and pressure, esophageal pressure, and Eadi were continuously recorded. Sixty tidal volumes for each ventilator settings were analyzed off-line, at three time points during inspiration. For each time point, Pmusc/Eadi index was calculated. Pmusc/Eadi index was also calculated from airway pressure drop during end-expiratory occlusions. Pmusc/Eadi index was very variable among patients, but within one patient it was not affected by type and level of ventilator assistance. Pmusc/Eadi index decreased during the inspiration. Pmusc/Eadi index obtained during an occlusion from airway pressure swing was tightly correlated with that derived from esophageal pressure during tidal ventilation and allowed to estimate pressure time product. CONCLUSIONS Pmusc is tightly related to Eadi, by a proportionality coefficient that we termed Pmusc/Eadi index, stable within each patient under different conditions of ventilator assistance. The derivation of the Pmusc/Eadi index from Eadi and airway pressure during an expiratory occlusion enables a continuous estimate of patient's inspiratory effort.
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Essouri S, Durand P, Chevret L, Balu L, Devictor D, Fauroux B, Tissières P. Optimal level of nasal continuous positive airway pressure in severe viral bronchiolitis. Intensive Care Med 2011; 37:2002-7. [DOI: 10.1007/s00134-011-2372-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 05/06/2011] [Indexed: 11/28/2022]
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Luo Y, Qiu Z, Wu H, Steier J, Jolley C, Zhong N, Moxham J, Polkey M. Neural drive during continuous positive airway pressure (CPAP) and pressure relief CPAP. Sleep Med 2009; 10:731-8. [DOI: 10.1016/j.sleep.2008.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 06/07/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
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Demoule A, Brochard L. [Study of respiratory muscle function in intensive care: recent advances (1998-2004)--ATS/ERS workshop]. Rev Mal Respir 2005; 22:499-506. [PMID: 16227942 DOI: 10.1016/s0761-8425(05)85584-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A Demoule
- Unité de Réanimation, Service de Pneumologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris et UPRES EA 2397, Université Pierre et Marie Curie Paris VI, Paris, France.
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Sharshar T, Ross ET, Hopkinson NS, Porcher R, Nickol AH, Jonville S, Dayer MJ, Hart N, Moxham J, Lofaso F, Polkey MI. Depression of diaphragm motor cortex excitability during mechanical ventilation. J Appl Physiol (1985) 2004; 97:3-10. [PMID: 15020575 DOI: 10.1152/japplphysiol.01099.2003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The effect of mechanical ventilation on the diaphragm motor cortex remains unknown. We assessed the effect of mechanical ventilation on diaphragm motor cortex excitability by measuring the costal and crural diaphragm motor-evoked potential (MEP) elicited by single and paired transcranial magnetic stimulation. In six healthy subjects, MEP recruitment curves of the costal and crural diaphragms were assessed at relaxed end expiration during spontaneous breathing [baseline tidal volume (Vtbaseline)] and isocapnic volume cycled ventilation delivered noninvasively (NIV) at three different levels of tidal volume (Vtbaseline, Vtbaseline + 5 ml/kg liters, and Vtbaseline + 10 ml/kg liters). The costal and crural diaphragm response to peripheral stimulation of the right phrenic nerve was not reduced by NIV. NIV reduced the costal and crural MEP amplitude during NIV ( P < 0.0001) with the maximal reduction at Vtbaseline + 5 ml/kg. Response to paired TMS showed that NIV (Vtbaseline + 5 ml/kg) significantly increased the sensitivity of the cortical motoneurons to facilitatory (>9 ms) interstimulus intervals ( P = 0.002), suggesting that the diaphragm MEP amplitude depression during NIV is related to neuromechanical inhibition at the level of motor cortex. Our results demonstrate that mechanical ventilation directly inhibits central projections to the diaphragm.
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Affiliation(s)
- Tarek Sharshar
- Respiratory Muscle Laboratory, Royal Brompton Hospital, Sydney St, London SW3 6NP UK
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Abraham E, Andrews P, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pinsky M, Radermacher P, Ranieri M, Richard C, Tasker R, Vallet B. Year in review in Intensive Care Medicine-2003. Part 1: Respiratory failure, infection and sepsis. Intensive Care Med 2004; 30:1017-31. [PMID: 15170528 DOI: 10.1007/s00134-004-2321-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2004] [Indexed: 11/25/2022]
Affiliation(s)
- Edward Abraham
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, CO, USA
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