Vocal cord dysfunction causing hypoxaemia in the postanaesthesia care unit

Hypoxaemia in the postanaesthesia care unit is common and the majority is caused by hypoventilation or upper airway obstruction due to the (residual) effects of anaesthetic and analgesic agents. We present a case of upper airway obstruction caused by vocal cord dysfunction, a less frequently occurring aetiology. The patient's case suggests a notable relationship between procedural laryngeal stimulus and the onset of symptoms. Approach to the diagnosis and flexible laryngoscopy to either rule-in or rule-out several relevant differentials are discussed.

Acceptance and long-term compliance of nCPAP in obstructive sleep apnea

In a retrospective cohort study, we evaluated whether improvements in nasal continuous positive airway pressure (nCPAP) technology, particularly the introduction of automatic adjustment of the nCPAP pressure (auto-CPAP), have led to better acceptance and (long-term) compliance in patients with obstructive sleep apnea syndrome (OSAS) as compared to earlier reported data. Questionnaires were sent to 256 patients, who were referred to our clinic for an overnight polysomnography from January 1997 to July 2005 and received nCPAP therapy for OSAS. Of the 256 patients, 24 patients were unavailable for follow-up. Of the remaining 232 patients, 58 patients (25%) had discontinued therapy, while 174 patients (75%) were still using nCPAP after 2 months to 8 years of follow-up. One Hundred and thirty eight (79%) of these 174 patients used nCPAP for at least 4 h/night during >or= 5 nights/week, 82,1% of the conventional nCPAP (fixed pressure CPAP) group (n = 78) and 77,1% of the auto-CPAP group (n = 96). Therefore, including the 58 failures, only 59.5% of patients can be seen as compliant. There were no statistical differences between the fixed pressure CPAP and auto-CPAP users, and between the compliant and non-compliant users according to age, BMI, AHI and Epworth sleepiness scale (ESS). Auto-CPAP patients used significantly more cm H2O. The long-term compliance of nCPAP therapy has have increased only slightly since the introduction of the fixed pressure CPAP 25 years ago, in spite of many efforts to improve it. It seems that a plateau has been reached and that it is unrealistic to aim at a substantially higher compliance rate.

Long-term outcome after 60 days of intensive care

Patients with a long stay in the intensive care unit because of chronic critical illness consume many resources, and yet their outcome may be poor. We evaluated the long-term outcome of patients spending more than 60 days in the intensive care unit. We performed a retrospective cohort and prospective follow-up study of 78 patients staying more than 60 days in the 19-26 bed mixed intensive care unit of a university hospital from November 1995 to January 2003. The mortality in the intensive care unit was 38%; at 1 and 5 years it was 56% and 67%, respectively. Advanced age, prior pulmonary disease, long duration of renal replacement therapy, a low oxygenation ratio and platelet count and high Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores on day 60 influenced long-term mortality. A Simplified Acute Physiology Score II of 50 or a Sequential Organ Failure Assessment score of 8 or higher was associated with 100% mortality during follow-up. The overall 5-year survival rate of 33% suggests that prolonged intensive care may be worth the effort in certain patients.