急性呼吸不全に対する人工呼吸戦略の潮流

急性呼吸不全に対する人工呼吸戦略の潮流

In the second half of the 20th century, the polio epidemic led to dramatic advances in positive pressure mechanical ventilation. However, it has become known that mechanical ventilation itself exacerbates lung injury and increase mortality (ventilator-induced lung injury, VILI). Over the past 20 years, numerous studies have been conducted to minimize the risk of VILI, and lung protective ventilation strategies consisting of low tidal volume, low plateau and driving pressure, and the use of appropriate end-expiratory positive pressure, became standard of care for acute respiratory distress syndrome (ARDS). Furthermore, in recent years, it has revealed that excessive respiratory effort exacerbates lung injury (patient self-inflicted lung injury, P-SILI), and the importance of controlling excessive respiratory effort has been recognized. However, strong suppression of respiratory effort leads to diaphragm atrophy, which may affect patient outcomes. Therefore, lung- and diaphragm-protective ventilation, which consists of monitoring respiratory effort closely and maintaining the effort at an appropriate level, has been proposed as a concept to avoid diaphragm atrophy while preventing P-SILI. Nevertheless, the mortality rate of ARDS is still high. Today, there is a need to move away from standardized treatment and to tailor ventilatory management to the individual risk of each patient.


急性呼吸不全における横隔膜保護的人工呼吸戦略

急性呼吸不全における横隔膜保護的人工呼吸戦略

Journal of the Japanese Society of Intensive Care Medicine


経肺圧を指標としたPEEP設定により，致死的低酸素血症から改善した神経芽細胞種に伴う腹部コンパートメント症候群の一乳児症例

Background : Neuroblastoma is the most common extracranial solid tumor of childhood. Although the prognosis of neuroblastoma is relatively good, newborns less than two months of age with stage 4S neuroblastoma may present with aggressive hypoxia and restrictive respiratory impairment due to abdominal compartment syndrome. Case presentation : Two-month-old girl, height of 63 cm and body weight of 10 kg. She was diagnosed as neuroblastoma with Stage 4S. Because she was suffered from refractory hypoxemia and restrictive respiratory impairment due to abdominal compartment syndrome induced by multiple liver metastasis and massive ascites, she was transferred to our ICU. Her trachea was intubated and ventilated with assist/controlled mode, driving pressure 22 cmH2O, positive end-expiratory pressure(PEEP)8 cmH2O, fraction of inspiratory oxygen(FIO2)1.0, but tidal volume was obtained only 3.2 mL/kg and PaO2/FIO2 ratio of 55 mmHg. Therefore, we insert esophageal sensor and monitored esophageal pressure to performed transpulmonary pressure guided PEEP titration. When we changed PEEP from 8 to 15 cmH2O so that the end-expiratory transpulmonary pressure achieving 0 to 5 cmH2O, her oxygenation(PaO2/FIO2 ratio : 55 to 178 mmHg)and respiratory compliance(1.4 to 3.0 mL/cmH2O)were dramatically improved. Her respiratory condition was further stabilized by ascites puncture and radiotherapy, and the patient was extubated successfully on the 25th ICU day. Conclusions : Although pediatric neuroblastoma with stage 4S may induce severe respiratory efficiency, the responsiveness of treatment for neuroblastoma is promising. Multimodal treatments including optimal ventilator management such as transpulmonary pressure -guided PEEP titration contributes to improved patient's prognosis.


Relationships between double cycling and inspiratory effort with diaphragm thickness during the early phase of mechanical ventilation: A prospective observational study.

Double cycling on the third day of mechanical ventilation was associated with strong inspiratory efforts and, possibly, changes in diaphragm thickness.


Independent lung ventilation for the management of acute allograft rejection after single-lung transplantation for end-stage emphysema.

Background : We herein report the use of independent lung ventilation (ILV) for managing acute allograft rejection after single-lung transplantation (SLT) for end-stage emphysema. Case presentation : A 54-year-old woman was transferred to our hospital with severe hypoxemia and respiratory distress due to unilateral lung disease with diffuse alveolar damage in the right donor lung associated with acute allograft rejection and with hyperinflation of the left native lung due to emphysema. She was unresponsive to immunosuppressive medications and conventional ventilation strategies, so different ventilator settings for each lung were required. A double-lumen endotracheal tube (DLT) was inserted, and ILV was initiated. The right lung was ventilated with high positive end-expiratory pressure (PEEP), intended for lung recruitment, and the left lung was ventilated with lung protective strategies using a low tidal volume and low levels of PEEP to avoid hyperinflation. Two days later, her lung function was dramatically improved, and the DLT was replaced with a single-lumen endotracheal tube. Gas exchange was maintained, and she was successfully weaned from mechanical ventilation on intensive-care unit day 15. Conclusions : ILV appears to be effective and safe for managing acute allograft rejection after SLT for emphysema. J. Med. Invest. 69 : 323-327, August, 2022.

The Journal of Medical Investigation : JMI


集中治療部設置のための指針 2022年改訂版

集中治療部設置のための指針 2022年改訂版


Acquired laryngomalacia as a cause of post-extubation respiratory failure in patient with postoperative seizure and central pontine myelinolysis after craniotomy.

Background : Laryngomalacia is a congenital abnormality of the larynx that commonly occurs in children and rarely in adults. We report the first case of acquired laryngomalacia mainly due to postoperative seizure and central pontine myelinolysis after scheduled craniotomy. Case presentation : A 69-year-old man was admitted to the hospital for elective craniotomy for craniopharyngioma. After the surgery, he developed refractory seizure and required intubation and mechanical ventilation in the intensive-care unit (ICU). After treatment for the seizure, he was extubated. However, immediately after extubation, he developed stridor and respiratory retraction. We performed fiberoptic laryngoscopy and confirmed that the epiglottis had collapsed into the posterior wall of the pharynx during inspiration, which was suspected to be laryngomalacia. He received invasive mechanical ventilation for two days following re-extubation. After the second extubation, he developed stridor again due to acquired laryngomalacia. Six days later, his respiratory condition had worsened, and he received re-intubation and tracheostomy. After ICU discharge, central pontine myelinolysis was diagnosed by magnetic resonance imaging. Conclusions : Adult-onset laryngomalacia is a rare cause of upper airway obstruction but should be considered as a cause of postoperative extubation failure. We should not delay performing fiberoptic laryngoscopy to evaluate this pathology and provide optimal treatment. J. Med. Invest. 69 : 316-319, August, 2022.


The quality and quantity of sleep on dexmedetomidine during high-flow nasal cannula oxygen therapy in critically ill patients.

Purpose : High-flow nasal cannula oxygen therapy (HFNC) is a new type of non-invasive respiratory support for acute respiratory failure patients. However, patients receiving HFNC often develop sleep disturbances. We therefore examined whether dexmedetomidine could preserve the sleep characteristics in patients who underwent HFNC. Patients and Methods : This was a pilot, randomized controlled study. We assigned critically ill patients treated with HFNC to receive dexmedetomidine (0.2 to 0.7 µg / kg / h, DEX group) or not (non-DEX group) at night (9:00 p.m. to 6:00 a.m.). Polysomnograms were monitored during the study period. The primary outcomes were total sleep time (TST), sleep efficiency and duration of stage 2 non-rapid eye movement (stage N2) sleep. Results : Of the 28 patients who underwent randomization, 24 were included in the final analysis (12 patients per group). Dexmedetomidine increased the TST (369 min vs. 119 min, p = 0.024) and sleep efficiency (68% vs. 22%, P = 0.024). The duration of stage N2 was increased in the DEX group compared with the non-DEX group, but this finding did not reach statistical significance. The incidences of respiratory depression and hemodynamic instability were similar between the two groups. Conclusions : In critically ill patients who underwent HFNC, dexmedetomidine may optimize the sleep quantity without any adverse events. J. Med. Invest. 69 : 266-272, August, 2022.


Diaphragm-protective mechanical ventilation in acute respiratory failure.

Mechanical ventilation injures not only the lungs but also the diaphragm, resulting in dysfunction associated with poor outcomes. The chief mechanisms of ventilator-induced diaphragm dysfunction are : disuse atrophy due to insufficient contraction and excessive ventilatory support ; concentric load-induced injury due to excessive contraction and insufficient ventilatory support ; eccentric load-induced injury due to contraction during the expiratory phase ; and longitudinal atrophy caused by high positive end-expiratory pressure. To protect the diaphragm during mechanical ventilation, maintaining proper levels of diaphragm contraction is paramount ; thus, monitoring of respiratory effort and finely tuned ventilator settings are necessary. Furthermore, maintaining of synchronization between the patient and the ventilator is also important. As diaphragm dysfunction is more likely to occur in critically ill patients, diaphragm-protective mechanical ventilation strategies are essential to reduce the mortality rate of intensive care unit patients. This review outlines clinical evidence of ventilator-induced diaphragm dysfunction and its underlying mechanisms, and strategies to facilitate diaphragm-protective mechanical ventilation. J. Med. Invest. 69 : 165-172, August, 2022.


ARDS に対する長期人工呼吸管理中に不動に伴う高 Calcium 血症を呈した 1例

Immobilization hypercalcemia is a rare complication in critically ill patients and causes weakness and gastrointestinal symptoms, symptoms that may lead to delayed rehabilitation and mobilization. A45-year-old woman developed ARDS and received prolonged mechanical ventilation. She received deep sedation to control excessive inspiratory effort and agitation until the 10th day. She developed hypercalcemia, which induced nausea and vomiting, on the fifth day. It was difficult to implement early physical rehabilitation and mobilization due to hypercalcemic symptoms. She was diagnosed with immobilization hypercalcemia and received alendronate sodium and elcatonin. The serum corrected calcium rapidly normalized and nausea disappeared after these drugs administration. After that, she underwent rehabilitation and was liberated from mechanical ventilation on the 63rd day. For the diagnosis of immobilization hypercalcemia, it is important to recognize risk factors such as long-term immobility, obesity, and an internal history of antiestrogens preparation. We should consider pharmacological intervention if it is difficult to implement early rehabilitation and mobilization due to symptoms of hypercalcemia.


Effect of High-Flow Nasal Cannula on Sleep-disordered Breathing and Sleep Quality in Patients With Acute Stroke.

Introduction Sleep-disordered breathing (SDB) is common after stroke. Although the standard treatment of SDB is continuous positive airway pressure (CPAP) ventilation, the patient's intolerance and discomfort result in low adherence rates. Alternatively, high-flow nasal cannula (HFNC) may be useful as it reduces upper airway collapse with low level of positive pressure and well tolerability. The aim of this study was to investigate whether HFNC therapy reduces SDB and improves sleep quality with higher compliance rate. Methods We included acute stroke patients with SDB for the assessment of apnea-hypopnea index (AHI) >5/h using WatchPAT 200 (Itamar Medical Ltd, Caesarea, Israel). Patients who met inclusion criteria received HFNC therapy (40 L/min) with monitoring by WatchPAT. AHI, oxygen desaturation index (ODI), sleep efficiency, and rapid eye movement (REM) sleep were compared in patients with and without HFNC therapy. We also evaluated the patient's comfort of HFNC therapy (discomfort or not). Results Among 17 patients assessed for AHI, 12 received HFNC therapy. HFNC therapy was not adhered in two patients due to intolerance. Eight patients remained for final analysis. There were no differences in SDB and sleep quality with and without HFNC therapy as follows: HFNC therapy vs control; AHI 24.9 ± 20.1 vs 21.3 ± 15.0/h (p = 0.63), ODI 16.2 ± 16.5 vs 12.9 ± 12.3/h (p = 0.54), sleep efficiency 80.4 ± 12.9 vs 87.1 ± 6.2 (p = 0.28), percentage of REM sleep 19.4% ± 9.6% vs 27.6% ± 8.9% (p = 0.07). Two patients (17%) complained of discomfort among eight patients. Conclusion HFNC therapy did not improve SDB and sleep quality. Nonadherence and discomfort were observed in HFNC therapy. We need a large trial to confirm this result.


側弯矯正固定術後の急性換気不全に対し気管支鏡による選択的気管支拡張術が奏功した1例

日本集中治療医学会第4回中国・四国支部学術集会

日本集中治療医学会第4回中国・四国支部学術集会


Urinary Titin Is a Novel Biomarker for Muscle Atrophy in Nonsurgical Critically Ill Patients: A Two-Center, Prospective Observational Study.

In nonsurgical critically ill patients, urinary titin level increased 10-30 times compared with the normal level. The increased urinary titin level was associated with lower limb muscle atrophy, occurrence of ICU-acquired weakness, and ICU mortality.


急性呼吸不全を合併した免疫不全患者に対する呼吸療法がICU転帰に与える影響∼NPPVとHFNCの比較∼

Background : Non-invasive positive pressure ventilation (NPPV) is highly recommended for immunocompromised patients with acute respiratory failure. In this population it remains uncertain, however, whether high flow nasal canula(HFNC)is as beneficial as NPPV. Methods : We retrospectively studied immunocompromised patients with acute respiratory failure admitted to our ICU from 2011 to 2018. The background and clinical outcomes of patients initially treated with HFNC and NPPV were compared. Results : Upon admission, 12 patients were treated with HFNC and 10 with NPPV. While the length of ICU stay was significantly shorter in HFNC group (HFNC4．6days vs. NPPV13．8days, p=0．02), no intergroup difference was seen in ICU mortality (16．7% vs.30．0%, p=0．46)or intubation rate(33．3% vs.50．0%, p=0．43). Conclusions : For immunocompromised patients with acute respiratory failure, HFNC may be an alternative to NPPV. Further prospective investigation is warranted.


当院ICUにおけるカルバペネム系抗菌薬の使用状況とde-escalationに関する検討．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


目標換気量の表示が人工呼吸患者の低一回換気量/肺保護換気の順守率に与える影響．

目標換気量の表示が人工呼吸患者の低一回換気量/肺保護換気の順守率に与える影響．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


人工呼吸開始後早期の患者-人工呼吸器非同調が横隔膜厚の変化に与える影響．

人工呼吸開始後早期の患者-人工呼吸器非同調が横隔膜厚の変化に与える影響．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


NPPVとハイフロー療法どっちがいいの?「急性呼吸不全におけるネーザルハイフローセラピーの現況」

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: A prospective observational ultrasougraphy study


Monitoring of muscle mass in criticaly ill patients: comparison of ultrasound and two bioelectrical impedance analysis devices

Skeletal muscle atrophy commonly occurs in critically ill patients, and decreased muscle mass is associated with worse clinical outcomes. Muscle mass can be assessed using various tools, including ultrasound and bioelectrical impedance analysis (BIA). However, the effectiveness of muscle mass monitoring is unclear in critically ill patients. This study was conducted to compare ultrasound and BIA for the monitoring of muscle mass in critically ill patients. We recruited adult patients who were expected to undergo mechanical ventilation for > 48 h and to remain in the intensive care unit (ICU) for > 5 days. On days 1, 3, 5, 7, and 10, muscle mass was evaluated using an ultrasound and two BIA devices (Bioscan: Malton International, England; Physion: Nippon Shooter, Japan). The influence of fluid balance was also evaluated between each measurement day. We analyzed 93 images in 21 patients. The age of the patients was 69 (interquartile range, IQR, 59-74) years, with 16 men and 5 women. The length of ICU stay was 11 days (IQR, 9-25 days). The muscle mass, monitored by ultrasound, decreased progressively by 9.2% (95% confidence interval (CI), 5.9-12.5%), 12.7% (95% CI, 9.3-16.1%), 18.2% (95% CI, 14.7-21.6%), and 21.8% (95% CI, 17.9-25.7%) on days 3, 5, 7, and 10 ( < 0.01), respectively, with no influence of fluid balance ( = 0.04, = 0.74). The muscle mass did not decrease significantly in both the BIA devices (Bioscan, = 0.14; Physion, = 0.60), and an influence of fluid balance was observed (Bioscan, = 0.37, < 0.01; Physion, = 0.51, < 0.01). The muscle mass assessment at one point between ultrasound and BIA was moderately correlated (Bioscan, = 0.51, < 0.01; Physion, = 0.37, < 0.01), but the change of muscle mass in the same patient did not correlate between these two devices (Bioscan, = - 0.05, = 0.69; Physion, = 0.23, = 0.07). Ultrasound is suitable for sequential monitoring of muscle atrophy in critically ill patients. Monitoring by BIA should be carefully interpreted owing to the influence of fluid change. UMIN000031316. Retrospectively registered on 15 February 2018.


Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study.

Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.

The Journal of Medical Investigation : JMI


第47回日本救急医学会総会

第47回日本救急医学会総会


当院脳卒中センターにおける急性脳主幹動脈閉塞症例での病院前皮質症状評価の検討．

当院脳卒中センターにおける急性脳主幹動脈閉塞症例での病院前皮質症状評価の検討．

第47回日本救急医学会総会

第47回日本救急医学会総会


ステロイドパルス療法により未診断の重症筋無力症の初期増悪から呼吸不全をきたした一症例

Journal of Japanese Association for Acute Medicine


Changes of diaphragm function before and after withdrawal of high flow nasal cannula in patients with acute respiratory failure.

The 32nd Annual Congress of European Society of Intensive Care Medicine, Berlin, Germany


Long-term mobilization by a multidisciplinary team liberated a case of an acute respiratory distress syndrome (ARDS) from prolonged mechanical ventilation.

長期間の多職種連携による離床により人工呼吸器からの離脱に成功したacute respiratory distress syndrome (ARDS)の1症例

Early mobilization is an effective way to improve the physical function of critically ill patients, but there are numerous barriers to mobilization. One such is an early ward transfer. Mobilization is often insufficient in a ward, and the patient cannot be liberated from mechanical ventilation. We experienced a case of a successfully liberated patient from prolonged mechanical ventilation in long-term mobilization as orchestrated by a multidisciplinary team in the ICU. A 45-year-old female was admitted to the ICU and placed on mechanical ventilation for acute respiratory distress syndrome(ARDS). We deployed a mobilization protocol, which was mostly restricted to passive exercise in the first 2 weeks after admission. On day 30, the patient recovered from unstable respiration, but could not be liberated from mechanical ventilation because of muscle weakness, diagnosed as ICU-acquired weakness. The patient was gradually mobilized and transferred to a chair on day 35, and she was able to stand on day 56. On day 65, she was completely liberated from mechanical ventilation and discharged from the ICU 70 days after her initial admission. Long-term mobilization is important for liberation of a patient from prolonged mechanical ventilation as well as early mobilization in the ICU.


Effect of controlled ventilation on diaphragm atrophy during assist-control ventilation: a post hoc analysis.

6th SG-ANZICS Intensive Care Forum, Singapore


Timing of tracheostomy in acute stroke patients.


Bacterial Contamination of Circuit Inner Surfaces After High-Flow Oxygen Therapy.

Bacterial contamination of inner surfaces of the circuit after high-flow oxygen therapy was relatively high.


Humidification Performance of Passive and Active Humidification Devices Within a Spontaneously Breathing Tracheostomized Cohort.

In spontaneously breathing subjects with tracheostomy, an heated-and-humidified high-flow system achieved higher absolute humidity than did an HME.


Effect of High-Flow Nasal Cannula on Thoraco-Abdominal Synchrony in Pediatric Subjects After Cardiac Surgery.

After cardiac surgery, HFNC oxygen therapy at 2 L/kg/min improved thoraco-abdominal synchrony and decreased breathing frequency in pediatric subjects. (Clinical trial registration: UMIN000023426.).


Reverse triggering induced by endotracheal tube leak in lightly sedated ARDS patient.

Reverse triggering is respiratory entrainment triggered by the ventilator especially seen among heavily sedated patients. We confirmed reverse triggering induced by auto-triggering in lightly sedated patient through an esophageal pressure monitoring. The reverse triggering frequently caused breath stacking with increased tidal volume. Physicians should be aware, even at an optimal level of sedation, that reverse triggering can develop, possibly caused by auto-triggering.


The effect of head rotation on efficiency of face mask ventilation in anaesthetised apnoeic adults: A randomised, crossover study.

Two patients were excluded due to protocol violation; thus, data from 38 patients were analysed. The mean expiratory tidal volume was significantly higher in the rotated head position than in the neutral position (612.6 vs. 544.0 ml: difference [95% confidence interval], 68.6 [46.8 to 90.4] ml, P < 0.0001).


electrical activity of the diaphragm during reverse triggering - a case report.


経鼻高流量療法/ネーザルハイフローセラピー:生理学的効果．

経鼻高流量療法/ネーザルハイフローセラピー:生理学的効果．


Patient-ventilator asynchrony during assisted mechanical ventilation

During mechanical ventilatory assistance, patient-ventilator asynchrony occurs frequently. To avoid patient-ventilator asynchrony, the ventilator gas delivery pattern must match the patient's breathing pattern. Asynchrony may cause one or more of the following: poor gas exchange; hyperinflation of the lung; increased work of breathing owing to ventilator-induced diaphragmatic dysfunction; increased duration of both mechanical ventilation and ICU length of stay; and greater mortality. However, patient-ventilator asynchrony is easily overlooked. There are three general types of asynchrony: trigger asynchrony, cycling asynchrony, and flow asynchrony. Trigger asynchrony - caused by auto-triggering, ineffective inspiratory efforts (missed triggering), double triggering, and reverse triggering - occurs when the ventilator does not start pressurization in synchrony with the patient's inspiratory effort. Cycling asynchrony occurs when the inspiratory time of patient, ventilator do not match, and may occur as premature cycling or delayed cycling. Flow asynchrony occurs when ventilator flow delivery does not match the inspiratory demand of the patient. To deal with this common problem, bedside clinicians need better understanding of causes, graphical characteristics and appropriate management of each asynchrony.

患者-人工呼吸器非同調(以下，非同調)は，人工呼吸中に見られる頻度の高い事象である．人工呼吸器のガス供給パターンと，患者の呼吸パターンにずれがある場合，非同調が生じる．非同調は，ガス交換障害，肺過膨張，呼吸仕事量の増大，人工呼吸期間やICU滞在期間の延長をきたし，患者予後への影響も指摘されているが，その認識は高いとは言えない．非同調は，(1)患者の吸気努力に一致して人工呼吸器の送気が開始しない不適切なトリガー(オートトリガー，ミストリガー，二重トリガー，逆行性トリガー)，(2)吸気から呼気へ転じるタイミングのずれ(送気の早期終了，送気の終了遅延)，(3)人工呼吸器の送気流量と患者の吸気流量の過不足，の3つに大別される．ベッドサイドの医療者には，これら非同調の原因，グラフィックモニタ波形上の特徴，対処方法について深い理解が求められる．

Journal of the Japanese Society of Intensive Care Medicine


Performance of Leak Compensation in All-Age ICU Ventilators During Volume-Targeted Neonatal Ventilation: A Lung Model Study.

Further clinical investigation is needed to validate the use of leak compensation during neonatal volume-targeted ventilation.


Effects of Leak Compensation on Patient-Ventilator Synchrony During Premature/Neonatal Invasive and Noninvasive Ventilation: A Lung Model Study.

During both nasal noninvasive ventilation (NIV) and invasive ventilation of neonates, the presence of air leaks causes triggering and cycling asynchrony. Five ICU ventilators (PB840, PB980, Servo-i, V500, and Avea) were compared in available invasive ventilation and NIV ventilator modes (pressure control continuous spontaneous ventilation [PC-CSV] and pressure control continuous mandatory ventilation [PC-CMV]). The V500 and Avea do not provide PC-CSV and PC-CMV in NIV. The Servo-i and Avea were tested with and without their proximal flow sensor. The ASL 5000 lung model (version 3.5) was used to simulate 4 neonatal scenarios (body weight 0.5, 1, 2, and 4 kg). The ASL 5000 was ventilated via endotracheal tube (invasive ventilation) or nasal cannula (NIV) with 4 different leaks. The Avea (without flow sensor) during invasive ventilation and Servo-i and PB840 during NIV were not triggered by inspiratory efforts of the ASL 5000 at the baseline leak in the 0.5 kg scenario. In invasive ventilation, overall (median) asynchrony index was significantly lower with the PB980 (1%) and V500 (3%) than with the Servo-i (with flow sensor, 50%; without flow sensor, 50%) and Avea (with sensor, 50%; without sensor, 62%) (P < .05 for all comparisons). The PB840 (33%) was significantly different from all ventilators (P < .05). In NIV, the asynchrony index was significantly lower in PB980 (2%) than in the Servo-i (with sensor, 100%; without sensor, 100%) and PB840 (75%) (P < .05 for both). There was no difference in asynchrony index between PC-CSV and PC-CMV in all tested conditions and ventilators. The ability of leak compensation to prevent asynchronous breathing varied widely between ventilators and lung mechanics. The PB980 and V500 were the only two ventilators to acclimate to all leak scenarios in invasive ventilation, and PB980 was the only ventilator to acclimate to all leak scenarios in NIV.


Hyperoxemia in mechanically ventilated, critically ill subjects: incidence and related factors.

During mechanical ventilation of critically ill subjects, P(aO2) increased, and F(IO2) decreased. One in 4 subjects were hyperoxemic at T2, and hyperoxemia persisted until T3.


開心術後の重篤な低酸素血症を発症した新生児を膜型人工肺で長期管理した一症例―ローラーポンプのトラブルと遠心ポンプでの流量安定化の試み―


Delayed Discharge from the Intensive Care Unit

集中治療室からの退室遅延の実態


この患者をどう管理する―躊躇わずに筋弛緩薬を用いて徹底して肺を守り，病態改善後は速やかに浅鎮静を目指す―．


Effect of high-flow nasal cannula on thoraco-abdominal synchrony in adult critically ill patients.

High-flow nasal cannula (HFNC) creates positive oropharyngeal airway pressure and improves oxygenation. It remains unclear, however, whether HFNC improves thoraco-abdominal synchrony in patients with mild to moderate respiratory failure. Using respiratory inductive plethysmography, we investigated the effects of HFNC on thoraco-abdominal synchrony. We studied 40 adult subjects requiring oxygen therapy in the ICU. Low-flow oxygen (up to 8 L/min) was administered via oronasal mask for 30 min, followed by HFNC at 30-50 L/min. Respiratory inductive plethysmography transducer bands were circumferentially placed: one around the rib cage, and one around the abdomen. We measured the movement of the rib-cage and abdomen, and used the sum signal to represent tidal volume (V(T)) during mask breathing, and at 30 min during HFNC. We calculated the ratio of maximum compartmental amplitude (MCA) to V(T), and the phase angle. We assessed arterial blood gas and vital signs at each period, and mouth status during HFNC. We used multiple regression analysis to identify factors associated with improvement in thoraco-abdominal synchrony. During HFNC, breathing frequency significantly decreased from 25 breaths/min (IQR 22-27 breaths/min) to 21 breaths/min (IQR 18-24 breaths/min) (P < .001), and MCA/VT (P < .001) and phase angle (P = .047) significantly improved. HFNC improved thoraco-abdominal synchrony in adult subjects with mild to moderate respiratory failure.


The investigation of prognosis of hematological malignancies in ICU patients

集中治療室に入室した血液悪性腫瘍患者の予後の検討

As knowledge of the pathophysiology of organ dysfunctions has been increasing, so the survival of critically ill patients has been improving. After ICU admission, patients with hematological malignancies, however, are still at high risk. We retrospectively evaluated outcome, and risk factors related to mortality of such patients admitted to our ICU. Reviewing medical records of patients admitted between 2005 and 2011, we collected data for age, gender, reasons for ICU admission, Acute Physiology and Chronic Health Evaluation (APACHE) II score, presence and progress of underlying disease, number of organ dysfunction, pancytopenia, treatment with or without bone marrow transplantation, ventilatory support, including noninvasive positive pressure ventilation (NPPV), cause of death, length of ICU stay, ICU mortality, and hospital mortality. Of the 35 patients we found with hematological malignancies, 20 (57.1%) died in the ICU. ICU mortality was lower in patients with only NPPV than those who were intubated. Number of organ dysfunction was also related to ICU mortality. Patients with hematological malignancies remained poor prognosis. NPPV was thought to be effective to care respiratory failure of those who did not cause severe organ dysfunction.

重症患者の生存率は臓器障害の病態生理学の進歩により改善してきている．しかし血液悪性腫瘍患者の予後はICU入室後も依然として悪い．今回，当院ICUに入室した血液悪性腫瘍患者の予後に及ぼす背景因子を後方視的に調査した．2005年から2011年に入室した患者の年齢・性別・ICU入室理由・Acute Physiology and Chronic Health Evaluation(APACHE)IIスコア・基礎疾患・臓器障害・汎血球減少・骨髄移植・入室期間・呼吸管理〔noninvasive positive pressure ventilation(NPPV)を含む〕・死亡理由・ICU死亡率・院内死亡率を調査項目とした．35人が入室し，ICU死亡率は57.1%だった．NPPVのみで管理できた症例では，気管挿管を施行した症例に比べてICU死亡率が低かった．また臓器障害数とICU死亡率は関連を認めた．ICUに入室する血液悪性腫瘍患者の予後は依然不良であった．呼吸不全以外の臓器障害が軽度であれば，NPPVによる呼吸管理は呼吸不全の治療として有効であると考えられた．


過去11年間に当院集中治療部に入室した産科患者の臨床像の検討

過去11年間に当院集中治療部に入室した産科患者の臨床像の検討


Thiamylal sodium-induced leukopenia in a patient of tardive dystonia

チアミラールによる薬剤性白血球減少症が疑われた遅発性ジストニアの一症例．


A case of feeding tube-induced duodenal perforation in a critically ill infant after palliative cardiac surgery

栄養チューブによる十二指腸穿孔をきたした1乳児症例


A case of tongue necrosis due to an endotracheal tube

気管チューブにより舌壊死をきたした一例

Journal of the Japanese Society of Intensive Care Medicine


低体温療法中に著明なヘモグロビン値の変化を認めた3症例

低体温療法中に著明なヘモグロビン値の変化を認めた3症例