[Weaning of COPD patients from mechanical ventilation].

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD), a common disease worldwide, refers to two frequently coexisting lung diseases, chronic bronchitis and emphysema. Physiologically, COPD represents a disruption in ventilation and in the exchange of gases in the lungs. Laboratory tests indicate elevated CO2 level, gradual reduction of the levels of oxygen and pH in arterial blood and elevated PeCO2. It does not include other obstructive diseases such as asthma. OBJECTIVE: Patients with COPD represent a large portion of those artificially ventilated in an ICU. In an attempt to determine the length of ventilation and stay in ICU, we compared the length of ventilation, weaning, reintubation and discharge during a period of ten months. METHODS: This study included 73 patients on mechanical ventilation (MV) due to severe exacerbation of COPD that were not suitable for non-invasive ventilation. Each patient's arterial blood gases (ABG) were measured upon admission and PeCO2 was tested using a Datex S/5 instrument. RESULTS: All patients included in the study needed MV; 67 patients were ventilated from 5 to 161 hours (average 40 + 47), 6 patients need more than one week. Three of these patients died due to severe ventilated associated pneumonia. No correlation was found between pH, Pco2 and length of artificial respiration; these findings do not contribute to evaluation of the patient's condition nor do they enable us to predict the length of treatment necessary. CONCLUSION: Most of the patients (92%) ventilated for acute respiratory failure due to chronic obstructive pulmonary disease (COPD) needed MV for only between 40-47 hours.

Improved survival after acute myocardial infarction complicated by cardiogenic shock with circulatory support and transplantation: comparing aggressive intervention with conservative treatment.

BACKGROUND: The prognosis for patients with myocardial infarction has steadily improved, but remains poor for those developing cardiogenic shock. Utilization of re-vascularization, mechanical circulatory support and transplantation in these patients may improve survival. METHODS: We retrospectively analyzed the clinical outcome of 138 consecutive patients at the Cleveland Clinic from 1992 to 1998 who met the criteria for cardiogenic shock after acute myocardial infarction. All patients received intensive medical therapy and intra-aortic balloon pump support. Forty-three patients received intensive medical therapy (conservative group) and 95 patients were treated aggressively (aggressive group). The aggressive group comprised patients who were treated with percutaneous intervention/coronary artery bypass grafting (n = 77, re-vascularization group), and patients who received circulatory support/cardiac transplantation (n = 18). RESULTS: The baseline demographics and angiographic and hemodynamic features were comparable for the two groups. The in-hospital mortality rate was significantly reduced in the aggressive group compared with the conservative group (54% vs 81%, p = 0.002). The in-hospital mortality rate of the circulatory support/transplant group was markedly reduced compared with the conservative group (33% vs 81%, p < 0.001), and was also significantly lower than that of the re-vascularization group (33% vs 63%, p= 0.03). The aggressive group had a markedly improved 5-year survival compared with the conservative group (30% vs 6.2%, p = 0.003). CONCLUSIONS: These data suggest that an aggressive strategy, particularly left ventricular assist device support as a bridge to heart transplantation, may improve survival in post-myocardial infarction patients with cardiogenic shock.