Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use at home for chronic respiratory failure.

INTRODUCTION: To define approach of pulmonologists in Turkey to noninvasive mechanical ventilation (NIV) use for chronic respiratory failure (CRF), the most currently applied technique for home mechanical ventilation. PATIENTS AND METHODS: A 38-question survey, developed and tested by the authors, was distributed throughout Turkey to 2205 pulmonologists by e-mail. RESULT: Twenty-seven percent of the pulmonologists responded (n=596). Domiciliary NIV was reported to be prescribed by 340 physicians [57.1% of all responders and 81% of pulmonologists practicing NIV at clinical practice (n= 420)]. NIV prescription was associated with physician's title, type of hospital, duration of medical license, total number of patients treated with NIV during residency and current number of patients treated with NIV per week (p< 0.05). Main estimated indications were listed as chronic obstructive pulmonary disease (median, 25-75 percentile of the prescriptions: 75%, 60-85), obesity hypoventilation syndrome (10%, 2-15), overlap syndrome (10%, 0-20) and restrictive lung disease (5%, 2-10). For utilization of NIV at home, Bilevel positive airway pressure-spontaneous mode (40%, 0-80) and oronasal mask (90%, 60-100) were stated as the most frequently recommended mode and interface, respectively. Pressure settings were most often titrated based on arterial blood gas findings (79.2%). Humidifier was stated not to be prescribed by approximately half of the physicians recommending domicilliary NIV, and the main reason for this (59.2%) was being un-refundable by social security foundation. CONCLUSION: There is a wide variation in Turkey for prescription of NIV, which is supposed to improve clinical course of patients with CRF. Further studies are required to determine the possible causes of these differences, frequency of use and patient outcomes in this setting.

Risk factors for multiorgan failure and mortality in severe sepsis patients who need intensive care unit follow-up.

INTRODUCTION: Multiorgan failure (MOF) is a primary cause of morbidity and mortality in sepsis patients in intensive care units (ICU). Finding risk factors and solving preventable problems of MOF in patients who have sepsis can be a favourable step for decreasing mortality. We aimed to examine multiorgan failure and mortality related risk factors in intensive care unit patients who have sepsis. MATERIALS AND METHODS: A retrospective data collection and prognostic cohort study was performed. Between January 2009-March 2010, patients accepted to the 22-bed pulmonary intensive care unit with the diagnosis of sepsis were enrolled. Patients' demographic data, ICU severity scores, application of mechanical ventilation, causative agent of sepsis, number of ICU days and presence of mortality were recorded. Logistic regression analysis was carried out for risk factors. RESULT: 347 patients with sepsis were involved in the study. 43 of the patients (12.4%) developed MOF and overall mortality rate was 14.9% (n= 52). Presence of resistant pathogen, presence of shock, application of TPN and high APACHE II score were found to be risk factors for MOF [p= 0.015 Odds ratio (OR) 3.47 confidence interval (CI): 1.27 - 9.47, p= 0.001, OR: 30.8 CI: 11.41 - 83-49, p= 0.028, OR: 3.08, CI: 1.13 - 8.39, p= 0.003, OR: 1.10, CI: 1.04-1.18, respectively]. Risk factors for overall mortality were presence of nosocomial infection, high 3rd day SOFA score, presence of shock, application of TPN and sedation (p= 0.005, OR: 3.39, CI: 1.45 - 7.93; p= 0.001, OR: 1.51, CI: 1.27 - 1.81; p= 0.014, OR: 3.24, CI: 1.27 - 8.25; p= 0.003, OR: 3.64. CI: 1.54 - 8.58; p= 0.001, OR: 3.38, CI: 1.51 - 7.57, respectively). CONCLUSIONS: In sepsis patients who need ICU follow up, presence of resistant pathogen, presence of shock, application of TPN and high APACHE II scores are risk factors for developing MOF. Thus, rational use of antibiotics, reducing the use of TPN, application of infection control programmes and prevention of shock will further reduce multiorgan failure and mortality.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure.

INTRODUCTION: Noninvasive mechanical ventilation (NIV) has been increasingly used worldwide for acute respiratory failure (ARF), especially in patients with chronic lung disorders. We aimed to define the approach of pulmonologists in Turkey to NIV use for ARF management. MATERIALS AND METHODS: A 38-question survey, developed and tested by authors, was distributed by e-mail to a total of 2.205 pulmonologists in Turkey. RESULT: Response rate was 27% (n= 596). Seventy-one percent of responders were practicing NIV in clinic. NIV use was found to be associated with responder's academic title, age, duration of medical license, type of physician's hospital and its region, patient load, NIV experience during residency, and duration of NIV and intensive care unit (ICU) experience (p< 0.001). Based on sub-group analysis of responders using NIV, median number of NIV patients followed-up per week was 4 [interquartile range (IQR): 2-6]. Most of the NIV users reported employment of wards (90%) and/or ICUs (86%) to follow-up patients, while 8.4% of the responders were applying NIV only in ICU's. Chronic obstructive lung disease (COPD) (99.5%), obesity hypoventilation syndrome (93.7%) and restrictive lung disease (89.4%) were the most common indications. Majority of NIV users (87%) were applying NIV to > 60% of patients with COPD, and success rate in COPD was reported as over 60% by 93% of users. Oronasal mask (median and IQR 90, 80-100%, respectively) and home care NIV ventilators (median and IQR 50, 10-85%, respectively) were the most commonly utilized equipment. CONCLUSIONS: NIV use in ARF varies based on hospital type, region and, especially, experience of the physician. Although consistent with guidelines and general practice, NIV use can still be improved and increased.

Does Total Parenteral Nutrition Increase the Mortality of Patients with Severe Sepsis in the ICU?

OBJECTIVES: We aimed to evaluate the independent association between total parenteral nutrition (TPN) and nosocomial infection and intensive care unit (ICU) mortality in patients with severe pulmonary sepsis. MATERIAL AND METHODS: The present study was designed as a retrospective observational cohort study. We enrolled all patients with severe sepsis due to pulmonary infections who stayed more than 24 h in the respiratory ICU between January 2009 and December 2010. We recorded demographic characteristics, ICU severity scores, Acute Physiologic and Chronic Health Evaluation II (APACHE II) and first day Sequential Organ Failure Assessment (SOFA) score in the ICU, TPN because of intolerance to enteral feeding, ICU data, and mortality. To evaluate the risk factors for mortality, we performed adjusted logistic regression test for TPN, nosocomial infection, and SOFA in the model. RESULTS: Five hundred and fifty patients (males=375, females=175) with severe sepsis were involved in the study during the study period. The median and interquartile range (IQR) of age, APACHE II, and SOFA score at the time of admission to the ICU were 65 years (53-73), 20 (16-25), and 4 (3-6), respectively. Mortality rate was 18% (n=99). Adjusted odds ratio (OR), confidence intervals (CI) 95%, and p values of TPN, nosocomial infection, and first day SOFA score for mortality were as follows: OR:3.8, CI:2.3-6.1, p<0.001; OR:2.4, CI: 1.4-3.9, p<0.001; and OR: 1.3, CI:1.2-1.4, p<0.001, respectively. CONCLUSION: Nosocomial infection and the need for TPN because of intolerance of enteral nutrition (EN) is associated with a higher mortality rate in patients with severe sepsis in the ICU. Rational use of antibiotics and application of hospital acquired infection control program will further reduce mortality.

C-reactive protein as a predictor of mortality in patients affected with severe sepsis in intensive care unit.

BACKGROUND: Severe sepsis is a primary cause of morbidity and mortality in the intensive care unit (ICU). Numerous biomarkers have been assessed to predict outcome and CRP is widely used. However, the relevance for mortality risk of the CRP level and the day when it is measured have not been well studied. We aimed to assess whether initial and/or third dayCRP values are as good predictors of mortality in ICU patients with severe sepsis as other well-known complex predictors of mortality, i.e., SOFA scores. METHODS: An observational cohort study was performed in a 20-bed respiratory ICU in a chest disease center. Patients with severe sepsis due to respiratory disease were enrolled in the study. SOFA scores, CRP values on admission and on the third day of hospital stay, and mortality rate were recorded. ROC curves for SOFA scores and CRP values were calculated. RESULTS: The study included 314 ICU patients with sepsis admitted between January 2009 and March 2010. The mortality rate was 14.2% (n = 45). The area under the curve (AUC) for CRP values and SOFA scores on admission and on the 3rd day in ICU were calculated as 0.57 (CI: 0.48-0.66); 0.72 (CI: 0.63-0.80); 0.72 (CI: 0.64-0.81); and 0.76 (CI: 0.67-0.86), respectively. Sepsis due to nosocomial infection, a CRP value > 100 mg/L and higher SOFA scores on 3rd day, were found to be risk factors for mortality (odds ratio [OR]: 3.76, confidence interval [CI]: 1.68-8.40, p < 0.001, OR: 2.70, CI: 1.41-2.01, p < 0.013, and OR: 1.68, CI: 1.41-2.01, p < 0.0001, respectively). CONCLUSIONS: The risk of sepsis related mortality appears to be increased when the 3rd day CRP value is greater than 100 mg/dL. Thus, CRP appears to be as valuable a predictor of mortality as the SOFA score.

Evaluation of pulmonary hydatid cyst cases.

BACKGROUND: The incidence of pulmonary hydatid cyst has been high in developing countries such as Turkey. OBJECTIVE: The aim of this study was to evaluate the clinical presentation, treatment and outcomes of pulmonary hydatid cyst disease at a tertiary centre. METHODS: A total of 138 patients, aged between 9 and 72 years with pulmonary hydatid cyst were diagnosed between 2000 and 2008 in 2nd thoracic surgery clinic at our hospital. Clinical characteristics of patients, epidemiological features, cyst diameters and localizations, laboratory findings, surgical approaches were recorded and analyzed. RESULTS: The most frequent symptoms of pulmonary hydatid cyst were chest pain and cough (44.9%, 37.6%). According to cyst size, there was no difference between younger than twenty and older age groups (p>0.05). Twenty-two patients had complicated cyst cases. Most of them were symptomatic (90.9%). Association of complicated cyst with hepato-pulmonary involvement was significantly higher as compared with single hydatid cyst (p=0.01). Cystectomy was performed in 84.05% of patients and post-operative mortality was seen in only one patient due to pulmonary embolism. CONCLUSION: Association of lung and liver hydatid cyst increased the risk of occurrence of a complicated pulmonary hydatid cyst. Choice of surgical approach had satisfactory results and post-operative mortality was low.