Acute and Critical Care

ACC review series 2026: sepsis 2

Rapid microbiological diagnostics for sepsis in critical care: integrating technological advances with antimicrobial stewardship: Kye-Hyung Kim, Jongyoun Yi; Acute Crit Care. 2026;41(3):466-479. Published online August 31, 2026; DOI: https://doi.org/10.4266/acc.003224

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Abstract PDF: Sepsis is a life-threatening medical emergency in which prompt initiation of targeted antimicrobial therapy is crucial for patient survival. Historically, clinicians have relied on empirical broad-spectrum antibiotics owing to the 48-to-72-hour turnaround time of conventional blood cultures, while traditional host-response biomarkers offer limited pathogen-specific utility. This review highlights the recent paradigm shift in the microbiological diagnostics for sepsis, which is transitioning from conventional methods to rapid diagnostic tests (RDTs). Pre-analytic considerations for blood culture are of paramount importance as the foundation for all downstream RDT applications. We explore the clinical integration of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and highly multiplexed genotypic assays, which provide rapid species identification and limited profiles of genotypic resistance directly from positive blood cultures. The critical need for rapid phenotypic antimicrobial susceptibility testing is addressed, alongside the emerging technologies for culture-independent microbial detection. Crucially, technological advancement alone is insufficient: the true clinical benefits of RDTs would be achieved only when RDTs are coupled with robust diagnostic and antimicrobial stewardship programs. In the context of globally escalating antimicrobial resistance, and with a specific focus on the high prevalence of multidrug-resistant organisms in South Korea, the seamless integration of these advanced diagnostic systems into multidisciplinary clinical workflows underscores the urgency and opportunities of this paradigm shift.

Original Articles

Nursing
Minimizing discard volume to 2 ml before blood sampling from a central venous catheter: a prospective observational study in India: Abinaya Pushparaj, Lakshmi Ramamoorthy, Manu Ayyan S, Rajeswari Murugesan, Hmar Thiak Lalthanthuami; Acute Crit Care. 2026;41(1):174-182. Published online February 9, 2026; DOI: https://doi.org/10.4266/acc.000792

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Background
Central venous catheters (CVCs) are essential for the treatment of critically ill patients. The practice of discarding varying volumes of blood before sampling from CVCs is widely adopted globally. However, there is no established consensus regarding the appropriate volume of blood to discard before sampling. Therefore, this study aims to compare serum electrolyte levels and hemogram measurements obtained via direct venous puncture with those derived from the proximal lumen of the CVC using a discard volume of 2 ml. Methods: Using a prospective observational study design, 105 patients from intensive care units of a tertiary care center were selected through a convenience sampling method. The parameters analyzed included serum electrolytes (sodium, potassium, and calcium) and complete blood counts (hemograms). Intraclass correlation and Bland-Altman plot analysis were employed to assess agreement between the two sampling methods. Results: The study showed high agreement between the two methods, with a P-value of <0.001, except for white blood cell. The presence of acidosis as a clinical confounder was the primary reason for the differences in agreement for potassium (P=0.018), hematocrit (P=0.006), mean corpuscular volume (P=0.041), mean corpuscular hemoglobin (P=0.034), mean corpuscular hemoglobin concentration (P=0.031), neutrophil (P=0.045), and eosinophil (P=0.553). Conclusions: This study suggests that discarding 2 ml of blood, rather than 3 ml or more, before routine sampling from CVCs is sufficient and may help to reduce iatrogenic blood loss in critically ill patients.

Citations

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Assessment of minimum discard volume for central venous catheter sampling: Validation via busulfan therapeutic drug monitoring in pediatric transplant patients
Fang Ye, Huiying Ye, Dongwei Cui, Xuanxuan Zhang, Sailan Luo, Yuan Luo, Sandip Patil
Frontiers in Pediatrics.2026;[Epub] CrossRef

Infection
Risk factors associated with development of coinfection in critically Ill patients with COVID-19: Erica M. Orsini, Gretchen L. Sacha, Xiaozhen Han, Xiaofeng Wang, Abhijit Duggal, Prabalini Rajendram; Acute Crit Care. 2022;37(3):312-321. Published online August 29, 2022; DOI: https://doi.org/10.4266/acc.2022.00136

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Abstract PDF

Background
At outset of the coronavirus disease 2019 (COVID-19) pandemic, the significance of bacterial and fungal coinfections in individuals with COVID-19 was unknown. Initial reports indicated that the prevalence of coinfection in the general population was low, but there was uncertainty regarding the risk of coinfection in critically ill patients.
Methods
Nine hundred critically ill adult patients with COVID-19 infection were enrolled in this observational case-control study. Patients with a coinfection (case) and patients without a coinfection (control) were compared using univariate and multivariable analyses. A subgroup analysis was performed on patients with coinfection, dividing them into early (infection within 7 days) and late (infection after 7 days) infection groups.
Results
Two hundred and thirty-three patients (25.9%) had a bacterial or fungal coinfection. Vasopressor use (P<0.001) and severity of illness (higher Acute Physiology and Chronic Health Evaluation III score, P=0.009) were risk factors for the development of a coinfection. Patients with coinfection had higher mortality and length of stay. Vasopressor and corticosteroid use and central line and foley catheter placement were risk factors for late infection (>7 days). There were high rates of drug-resistant infections.
Conclusions
Critically ill patients with COVID-19 are at risk for both community-acquired and hospital-acquired infections throughout their hospitalization for COVID-19. It is important to consider the development of a coinfection in clinically worsening critically ill patients with COVID-19 and consider the likelihood of drug-resistance when choosing an empiric regimen.

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SARS‐CoV‐2–Streptococcus pneumoniae Coinfection: A Narrative Review of Pathogenesis, Synergy, and Clinical Impact
Wannaporn Chatwitchanon, Kamontip Kongutsa, Wasu Supharattanasitthi, Teerawit Audshasai, Lei Yao
International Journal of Microbiology.2026;[Epub] CrossRef
The subsets of blood circulating T-cells associated with the development and prognosis of coinfection in patients with critical COVID-19
Xingming Li, Hongqiong Peng, Yunchuan Wang, Shiying He, Xueting Yang, Jiayue Chen
Frontiers in Immunology.2025;[Epub] CrossRef
Bacterial and Fungal Coinfections in COVID-19 Inpatients at a Tertiary Hospital in Surabaya, Indonesia, from November 2020 to February 2022
Naura Ghina Shabira, Agung Dwi Wahyu Widodo, Musofa Rusli
Current Internal Medicine Research and Practice Surabaya Journal.2025; 6(1): 11. CrossRef
Prevalence and risk factors associated with multidrug-resistant bacteria in COVID-19 patients
Abdu Aldarhami, Ahmed A. Punjabi, Abdulrahman S. Bazaid, Naif K. Binsaleh, Omar W. Althomali, Subuhi Sherwani, Omar Hafiz, Ali A. Almishaal
Medicine.2024; 103(10): e37389. CrossRef
PROFILE OF PATIENTS DIAGNOSED WITH COVID-19 INFECTION: A SINGLE-CENTER RETROSPECTIVE STUDY
Julia Węgrzynek-Gallina, Joanna Pilśniak, Aleksandra Pilśniak, Agnieszka Jarosińska, Marta Pietrukaniec, Michał Holecki
Health Problems of Civilization.2024; 18(2): 180. CrossRef
Prevalence of secondary infections and association with mortality rates of hospitalized COVID-19 patients
Khalifa Binkhamis, Alanoud S. Alhaider, Ayah K. Sayed, Yara K. Almufleh, Ghadah A. Alarify, Norah Y. Alawlah
Annals of Saudi Medicine.2023; 43(4): 243. CrossRef
Blood Stream Infections in COVID-19 Patients From a Tertiary Care Center in Lebanon: Causative Pathogens and Rates of Multi-Drug Resistant Organisms
Sarah B. Nahhal, Johnny Zakhour, Abdel Hadi Shmoury, Tedy Sawma, Sara F. Haddad, Tamara Abdallah, Nada Kara Zahreddine, Joseph Tannous, Nisrine Haddad, Nesrine Rizk, Souha S. Kanj
Mayo Clinic Proceedings: Innovations, Quality & Outcomes.2023; 7(6): 556. CrossRef

Pulmonary
Reliability of the Korean version of the Richards-Campbell Sleep Questionnaire: Jae Kyoung Kim, Ju-Hee Park, Jaeyoung Cho, Sang-Min Lee, Jinwoo Lee; Acute Crit Care. 2020;35(3):164-168. Published online August 31, 2020; DOI: https://doi.org/10.4266/acc.2020.00339

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Abstract PDF Supplementary Material

Background
Sleep disorders are common in critically ill patients. Unfortunately, sleep assessment is challenging in many intensive care units (ICUs). The Richards-Campbell Sleep Questionnaire (RCSQ) is a simple subjective tool that has been validated and used in many countries. This study aimed to evaluate the reliability of the Korean version of the RCSQ (K-RCSQ).
Methods
This prospective, cross-sectional, observational study was conducted in the ICUs of two hospitals. In total, 52 consenting patients answered questionnaires regarding their previous night’s sleep (K-RCSQ) and the noise they experienced (range, 0–100).
Results
The K-RCSQ showed excellent internal consistency of 0.960 by Cronbach’s alpha. The mean total score of the K-RCSQ was 41.9±28.9 (range, 0–100). The mean perceived ICU noise score was 40.7±28.1 (range, 0–90). There was a significant linear correlation between noise score and average K-RCSQ score (r=–0.37, P<0.001).
Conclusions
The K-RCSQ demonstrated excellent reliability (internal consistency). This simple tool may help assess sleep quality in critically ill patients and improve the quality of ICU care.

Citations

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Real-World Effects of Melanopic-Enhanced Classroom Lighting on Sleep, Mood, and Cognition in Male Korean Adolescents: A Field-Based Pilot Study
Sumin Bae, Eunji Hwang, Ki-Young Jung
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Subjective and objective sleep measurements in ICU Patients: A longitudinal analysis of 706 sleep episode pairs
Jiyeon Kang, Hyeonjin Cho
Intensive and Critical Care Nursing.2026; 94: 104380. CrossRef
Validation and cross-cultural adaptation into Spanish of the Richards-Campbell sleep questionnaire for the pediatric critical population: RCSQ-PED
Alicia Gomez-Merino, Patricia Luna-Castaño, Rafael Lobato-López, Paloma María Núñez-Yebra, Pedro Piqueras-Rodríguez, Marta Martín-Velasco, Natalia González-Martínez, Ana Carrasco-San José, Andrea Paola Castro-Cedeño, María López-Cabrejas, Desirée Alcaraz-
Sleep Medicine.2026; 142: 108861. CrossRef
Sleep quality assessment in hospitalized postoperative surgical patients: a COSMIN-based systematic review
Nunung Nurhayati, Agung Waluyo, I. Made Kariasa, Sali Rahadi Asih, Hening Pujasari, Bahrul Hayat
Frontiers in Sleep.2026;[Epub] CrossRef
Assessing psychometric properties of the revised Richards-Campbell Sleep Questionnaire based on COSMIN: a systematic review
Yanting Zhang, Jing Ming, Chong Cheng, Yuan Zhang, Yihua Yang, Xinbo Ding, Jing Ma
Frontiers in Medicine.2026;[Epub] CrossRef
Usability of the Richards-Campbell sleep questionnaire in individuals with schizophrenia living in the community
Etkin BAĞCI, Hatice ABAOĞLU, Gamze EKİCİ
Archives of Psychiatric Nursing.2026; 63: 152181. CrossRef
Effects of a non-pharmacological multicomponent intervention on delirium, sleep quality, and total sleep time among emergency intensive care unit patients in South Korea: a non-equivalent control group time-series study
Hye-Ji Kim, Mi-Kyoung Cho
Journal of Korean Biological Nursing Science.2026; 28(3): 401. CrossRef
Iliopsoas plane block does not improve pain after primary total hip arthroplasty in the presence of multimodal analgesia: a single institution randomized controlled trial
Ji Yeong Kim, Jong Seok Lee, Ji Young Kim, Eun Jang Yoon, Wootaek Lee, Seungyeon Lee, Do-Hyeong Kim
Regional Anesthesia & Pain Medicine.2025; 50(3): 257. CrossRef
Effects of nursing interventions applied at night on sleep quality and sleep effort of patients in the intensive care unit
Aynur Bahar, Mina Güner Muşluoğlu, Hilal Uygur
Psychology, Health & Medicine.2025; 30(9): 1947. CrossRef
Effects of a Multimodal Intervention on Sleep Quality and Duration in Intensive Care Unit Patients
Jieun Nam, Sukhee Ahn
Journal of Korean Critical Care Nursing.2025; 18(1): 70. CrossRef
Calidad del sueño en pacientes ingresados en una unidad de cuidados intermedios
Paula Itxaso Sirera-Pérez, Adriana Martín-Sanjoaquín, Beatriz Juandeaburre-Pedroarena, Itziar Luquin-Iturmendi, Rosana Goñi-Viguria
Enfermería Clínica.2025; 35(3): 102157. CrossRef
Sleep quality in patients admitted to an intermediate care unit
Paula Itxaso Sirera-Pérez, Adriana Martín-Sanjoaquín, Beatriz Juandeaburre-Pedroarena, Itziar Luquin-Iturmendi, Rosana Goñi-Viguria
Enfermería Clínica (English Edition).2025; 35(3): 102157. CrossRef
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Öznur Erbay Dalli, Nermin Kelebek Girgin
Nursing in Critical Care.2025;[Epub] CrossRef
Translation and Validation of the Richards–Campbell Sleep Questionnaire for Intensive Care Unit Patients in Morocco: Reliability and Validity Assessment
Abdelmajid Lkoul, Keltouma Oum’barek, Mohamed Amine Baba, Asmaa Jniene, Tarek Dendane
Clocks & Sleep.2025; 7(3): 31. CrossRef
A Randomized Controlled Trial to Evaluate the Analgesic Effectiveness of Periarticular Injections and Pericapsular Nerve Group Block for Patients Undergoing Total Hip Arthroplasty
Bora Lee, Tae Sung Lee, Jaewon Jang, Hyun Eom Jung, Kwan Kyu Park, Yong Seon Choi
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Yoon Hae Ahn, Hong Yeul Lee, Sang-Min Lee, Jinwoo Lee
Acute and Critical Care.2023; 38(3): 278. CrossRef
Psychometric properties of a Thai version of the Richards‐Campbell sleep questionnaire
Nuanprae Kitisin, Pawit Somnuke, Napat Thikom, Nattaya Raykateeraroj, Nisa Poontong, Chayanan Thanakiattiwibun, Karuna Wongtangman
Nursing in Critical Care.2022; 27(6): 885. CrossRef
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Ellaha Kakar, Matthijs Priester, Pascale Wessels, Arjen J.C. Slooter, M. Louter, M. van der Jagt
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Usefulness of Screening Criteria System Used by Medical Alert Team in a General Hospital: Hyejin Joo, So Hee Park, Sang Bum Hong, Chae Man Lim, Younsuck Koh, Young Seok Lee, Jin Won Huh; Korean J Crit Care Med. 2012;27(3):151-156.; DOI: https://doi.org/10.4266/kjccm.2012.27.3.151

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Abstract PDF

BACKGROUND
Rapid response team (RRT) is becoming an essential part of patient safety by the early recognition and management of patients on general hospital wards. In this study, we analyzed the usefulness of screening criteria of RRT used at Asan Medical Center.
METHODS
On a retrospective basis, we reviewed the records of 675 cases in 543 patients that were managed by RRT (called medical alert team in the Asan Medical Center), from July 2011 to December 2011. The medical alert team was acted by requests of attending doctors or nurses or the medical alert system (MAS) criteria composed of abnormal vital sign, neurology, laboratory data and increasing oxygen demand. We investigated the patterns of MAS criteria for targeting the patients who were managed by the medical alert team.
RESULTS
Respiratory distress (RR > 25/min) was the most common item for identifying patients whose condition had worsened. The criteria consist with respiratory distress and abnormal blood pressure (mean BP < 60 mmHg or systolic BP < 90 mmHg) found 70.0% of patients with deteriorated conditions. Vital sign (RR > 25/min, mean BP < 60 mmHg or systolic BP < 90 mmHg, pulse rate, PR > 130/min or < 50/min) and oxygen demand found 79.2% of them. Vital signs, arterial blood gas analysis (ABGA) with lactate level (pH, pO2, pCO2, and lactate) and O2 demand found 98.6% of patient conditions had worsened.
CONCLUSIONS
Vital signs, especially RR > 25/min is useful criteria for detecting patients whose conditions have deteriorated. The addition of ABGA data with lactate levels leads to a more powerful screening tool.

Citations

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Influence of the Rapid Response Team Activation via Screening by Nurses on Unplanned Intensive Care Unit Admissions
Ye-Ji Huh, Seongmi Moon, Eun Kyeung Song, Minyoung Kim
Korean Journal of Adult Nursing.2020; 32(5): 539. CrossRef
Early Experience of Medical Alert System in a Rural Training Hospital: a Pilot Study
Maru Kim
The Korean Journal of Critical Care Medicine.2017; 32(1): 47. CrossRef
Temporal patterns of change in vital signs and Cardiac Arrest Risk Triage scores over the 48 hours preceding fatal in‐hospital cardiac arrest
HyunSoo Oh, KangIm Lee, WhaSook Seo
Journal of Advanced Nursing.2016; 72(5): 1122. CrossRef
A combination of early warning score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock
Jung-Wan Yoo, Ju Ry Lee, Youn Kyung Jung, Sun Hui Choi, Jeong Suk Son, Byung Ju Kang, Tai Sun Park, Jin-Won Huh, Chae-Man Lim, Younsuck Koh, Sang Bum Hong
The Korean Journal of Internal Medicine.2015; 30(4): 471. CrossRef

Case Reports

H1N1 Influenza/A Associated ARDS Recovered without Mechanical Ventilatory Support: A Case Report: Byung Ook Lee, Jae Hee Lee, Sung Woon Park, Bo Min Kim, Jae Chol Choi, Jong Wook Shin, In Won Park, Byoung Whui Choi, Jae Yeol Kim; Korean J Crit Care Med. 2011;26(2):114-116.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.114

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Abstract PDF: An eighteen year-old female visited the ER in our hospital with fever of 38.5degrees C for 2 days. She also had cough, myalgia, and dyspnea. Chest PA and lung HRCT showed mild pulmonary edema at both hilar areas. However, she had severe hypoxia (PaO2; 58 mmHg in room air). RT-PCR for H1N1 influenza/A of pharyngeal swab was positive. Tamiflu (150 mg/d) with broad-spectrum antibiotics was prescribed. Two days later, her dyspnea aggravated and chest PA showed diffuse bilateral infiltration. PaO2 dropped to 70 mmHg (O2 10 L/min by face mask with reservoir bag). She was transferred to the MICU and the Tamiflu dose was doubled (300 mg/day). Mechanical ventilator was set aside to prepare respiratory failure. Fortunately, her symptoms and oxygenation improved and she was discharged with full recovery. Although, most cases of ARDS require mechanical ventilatory support, early and adequate dose of Tamiflu may avoid it in the case of ARDS developed by H1N1 influenza/A.

Acute Respiratory Distress Syndrome with Chemical Pneumonitis after Aspiration of Activated Charcoal: A Case Report: Suhyun Kim, Na Ree Kang, In Sohn, Heon Lee, Yoon Kyung Lee, Sook Hee Song; Korean J Crit Care Med. 2010;25(2):112-117.; DOI: https://doi.org/10.4266/kjccm.2010.25.2.112

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Abstract PDF

Charcoal has been commonly used for enteral detoxication although it causes few adverse effects. The major causes of morbidity and mortality secondary to activated charcoal therapy are pulmonary aspiration, gastrointestinal complication, and fluid and electrolyte abnormalities. Aspiration of charcoal is associated with pulmonary compromise due to increased microvascular permeability with concomitant lung edema, surfactant depletion, atelectasis, and obliterative bronchiolitis. Herein we report the case of a patient with acute respiratory distress syndrome with chemical pneumonitis after aspiration of activated charcoal in sorbitol with a review of the related literatures.

Citations

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Five Successful Experiences in the Treatment of Charcoal Aspiration with Bronchoscopic Toilet - A Case Report -
Young Il Kim, Jae-Seok Park, Jae Sung Choi, Sung-Shik Jou, Hyo-Wook Gil, Sae-Yong Hong
Korean Journal of Critical Care Medicine.2012; 27(3): 202. CrossRef
A Case of Activated Charcoal Aspiration Treated by Early and Repeated Bronchoalveolar Lavage
Han Min Lee, Jae-Seok Park, Jae Yun Kim, Ji Yeon Lee, Byung Kyu Ahn, Hyo-Wook Gil, Jae-Sung Choi
Tuberculosis and Respiratory Diseases.2012; 72(2): 177. CrossRef

Original Article

A Comparison of Adaptive Support Ventilation (ASV) and Conventional Volume-Controlled Ventilation on Respiratory Mechanics in Acute Lung Injury/ARDS: Ik Su Choi, Jung Eun Choi, Sang Bum Hong, Chae Man Lim, Younsuck Koh; Korean J Crit Care Med. 2009;24(2):59-63.; DOI: https://doi.org/10.4266/kjccm.2009.24.2.59

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Abstract PDF

BACKGROUND
ASV is a closed-loop ventilation system that guarantees a user-set minimum per-minute volume in intubated patients, whether paralyzed or with spontaneous breathing. Here, we tested the effects of ASV onrespiratory mechanics and compared them with volume-controlled ventilation (VCV).
METHODS
Thirteen patients meeting the criteria for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) were enrolled. All patients were paralyzed to eliminate spontaneous breathing. We started with VCV (VCV1), then used ASV followed by VCV modes (VCV2), maintaining minute volume as much as that of VCV1.
RESULTS
During ASV, compared with VCV1, the inspiratory and expiratory tidal volumes and expiratory resistance increased. Conversely, the total respiratory rate and maximum pressure decreased. No changes in the arterial blood gases, heart rate, or mean systemic pressure were noted during the trial.
CONCLUSIONS
In ALI/ARDS patients, although no differences were observed in the arterial blood gas analysis between the two modes, ASV provided better respiratory mechanics in terms of peak airway pressure and tidal volume than VCV.

Citations

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Comparison of adaptive support ventilation and synchronized intermittent mandatory ventilation in patients with acute respiratory distress syndrome
Babak Alikiaii, Saeed Abbasi, Hamideh Yari, Mojtaba Akbari, Parviz Kashefi
Journal of Research in Medical Sciences.2022; 27(1): 6. CrossRef
Comparison of Volume Support, Volume-Assured Pressure Support, and Spontaneous Modes in Postoperative Early Extubated Patients
Saeed Abbasi, Babak Alikiaii, Parviz Kashefi, Navid Haddadzadegan
Advanced Biomedical Research.2022; 11(1): 99. CrossRef
The Comparison Effects of Two Methods of (Adaptive Support Ventilation Minute Ventilation: 110% and Adaptive Support Ventilation Minute Ventilation: 120%) on Mechanical Ventilation and Hemodynamic Changes and Length of Being in Recovery in Intensive Care
Babak Ali Kiaei, Parviz Kashefi, Seyed Taghi Hashemi, Daryoush Moradi, Ahmad Mobasheri
Advanced Biomedical Research.2017;[Epub] CrossRef
Comparing the Effect of Adaptive Support Ventilation (ASV) and Synchronized Intermittent Mandatory Ventilation (SIMV) on Respiratory Parameters in Neurosurgical ICU Patients
Mohammadreza Ghodrati, Alireza Pournajafian, Ali Khatibi, Mohammad Niakan, Mohammad Hosein Hemadi, Mohammad Mahdi Zamani
Anesthesiology and Pain Medicine.2016;[Epub] CrossRef
Adaptive support ventilation for complete ventilatory support in acute respiratory distress syndrome: A pilot, randomized controlled trial
Ritesh Agarwal, Arjun Srinivasan, Ashutosh N. Aggarwal, Dheeraj Gupta
Respirology.2013; 18(7): 1108. CrossRef
Advanced Ventilator Modes and Techniques
Carl F. Haas, Kimberly A. Bauser
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Evaluation of Respiratory Parameters in Patients with Acute Lung Injury Receiving Adaptive Support Ventilation
Keu Sung Lee, Wou Young Chung, Yun Jung Jung, Joo Hun Park, Seung Soo Sheen, Sung Chul Hwang, Kwang Joo Park
Tuberculosis and Respiratory Diseases.2011; 70(1): 36. CrossRef

Review Article

Mechanical Ventilation in Patients with Chronic Obstructive Pulmonary Disease: Tae Hun An; Korean J Crit Care Med. 2003;18(2):67-73.

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Abstract PDF: Patients with severe chronic obstructive pulmonary disease (COPD) may require mechanical ventilation following cardiac or general surgery, in connection with thoracic surgery such as lobectomy, wedge resection, lung reduction or bullectomy, during an episode of acute respiratory failure (ARF) secondary to a disease other than COPD such as sepsis, drug overdose, or trauma or for acute-on-chronic respiratory failure (the COPD exacerbation) where acute illness, usually presumed to be infectious in nature, destabilizes the characteristically compensated state. Ventilatory intervention is often life-saving when patients with asthma or COPD experience acute respiratory compromise. Although both noninvasive and invasive ventilation methods may be viable initial choice, which is better depends upon the severity of illness, the rapidity of response, coexisting disease, and capacity of the medical environment. In addition, noninvasive ventilation often relieves dyspnea and hypoxemia in patients with stable severe COPD. This review will only briefly cover noninvasive ventilation and focus primarily on the management of the intubated, mechanically ventilated patient with COPD, with particular emphasis on factors unique to this patient population such as the propensity for dynamic hyperinflation and auto-PEEP, barotrauma, difficult weaning and the prognosis following mechanical ventilation.

Original Article

The Inhaled Nitric Oxide in Acute Respiratory Distress Syndrome: from a Bedside to a Bench: Younsuck Koh; Korean J Crit Care Med. 2001;16(2):65-74.

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Abstract PDF: Because inhaled nitric oxide (NO) induces selective vasodilation of well-ventilated lung regions diverting pulmonary artery blood flow towards these well-ventilated alveoli, it has been applied to some of ARDS patients, who show severe hypoxemia despite of positive pressure ventilation with moderate to high positive end-expiratory pressure. The beneficial effect of inhaled NO on oxygenation was lower than 5 ppm of inhaled NO and the maximum effect was about 10 ppm in patients with ARDS according to the studies. Combinations of inhaled NO with various therapies, such as the use of intravenous almitrine or phenylephrine, and prone positioning may produce additive effects on oxygenation. Approximately 65% of patients had response to inhaled NO in studies of critically ill patients with ARDS who were ventilated with less than 40 ppm of inhaled NO. However, there was no survival benefit by inhaled NO in a multicenter phase 2 trial with 177 patients of non-septic ARDS. It is unclear whether inhaled NO exerts detrimental or beneficial effects in the pathogenesis of ARDS. Laboratory studies suggest that inhaled NO has important effects in reducing some forms of lung and tissue injury. If these effects are clinically significant, early and continued therapy with inhaled NO could potentially reduce the severity of some forms of lung injury. In contrast, NO and nitrite interacted with neutrophil myeloperoxidase to stimulate oxidative reactions during inflammation. In summary, NO inhalation would be acceptable as a rescue therapy in severe ARDS without serious complications related to the application. In addition, the effect of inhaled NO on the pathophysiology of ARDS should be elucidated.

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