Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification o... more Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification of this condition could be of interest. The aim of this study was to evaluate whether a modified point-of-care viscoelastic hemostatic assay can detect sepsis-induced impairment of fibrinolysis and to correlate impaired fibrinolysis with morbidity and mortality. This single center observational prospective pilot study was performed in an adult Intensive Care Unit (ICU) of a tertiary academic hospital. Forty consecutive patients admitted to the ICU with severe sepsis or septic shock were included. Forty healthy individuals served as controls. We modified conventional kaolin activated thromboelastography (TEG) adding urokinase to improve assessment of fibrinolysis in real time (UK-TEG). TEG, UK-TEG, plasminogen activator inhibitor (PAI)-1, thrombin-activatable fibrinolysis inhibitor (TAFI), d-dimer, DIC scores and morbidity (rated with the SOFA score) were measured upon ICU admission. Logis...
INTRODUCTION. Veno-venous extracorporeal membrane oxygenation (ECMO) requires blood anticoagulati... more INTRODUCTION. Veno-venous extracorporeal membrane oxygenation (ECMO) requires blood anticoagulation to prevent activation of the coagulation cascade led by the presence of indwelling catheters and the extracorporeal circuit. Anticoagulation is usually achieved with Unfractionated Heparin (UH) infusion; however, variability of the anticoagulation degree and monitoring methods exists among centers [1]. Activated Partial Thromboplastin Time (aPTT) is one of the most frequently used monitoring methods. Thromboelastography (TEG) may be an alternative, point-of-care tool to monitor anticoagulation during extracorporeal membrane oxygenation, but it has been used only anecdotally. OBJECTIVES. To compare anticoagulation monitoring using aPTT, i.e. current clinical practice at our institution, with the reaction time (R) parameter at TEG. METHODS. Thirty-two consecutive patients undergoing femoro-femoral veno-venous ECMO for acute respiratory failure from December 2011 to August 2013 admitted ...
Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilatio... more Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilation, is the most common nosocomial infection in patients with acute respiratory failure. The major mechanism of lower respiratory tract colonization is aspiration of bacteria-colonized secretions from the oropharynx into the lower airways. The hydrostatic pressure of the secretions that collect in the subglottic space, which is the area above the endotracheal tube (ETT) cuff, or aerosolization of bacteria from the secretions collected within the respiratory tubing may facilitate the leakage into the lower airways. Ideally, the elimination of the mechanisms responsible for aspiration would decrease the incidence of VAP. Several preventive measures have been tested in clinical trials with little success.Here we present the results of our efforts to develop novel approaches for the prevention of VAP. Specifically, we found that keeping ventilated patients in a lateral position, which eliminat...
To compare the effect on respiratory function of different continuous positive airway pressure sy... more To compare the effect on respiratory function of different continuous positive airway pressure systems and periodic hyperinflations in patients with respiratory failure. Prospective Hospital intensive care unit. Sixteen intubated patients (eight men and eight women, age 54 +/- 18 yrs, PaO2/FiO2 277 +/- 58 torr, positive end-expiratory pressure 6.2 +/- 2.0 cm H2O). We evaluated continuous flow positive airway pressure systems with high or low flow plus a reservoir bag equipped with spring-loaded mechanical or underwater seal positive end-expiratory pressure valve and a continuous positive airway pressure by a Servo 300 C ventilator with or without periodic hyperinflations (three assisted breaths per minute with constant inspiratory pressure of 30 cm H2O over positive end-expiratory pressure). We measured the respiratory pattern, work of breathing, dyspnea sensation, end-expiratory lung volume, and gas exchange. We found the following: a) Work of breathing and gas exchange were comparable between continuous flow systems; b) the ventilator continuous positive airway pressure was not different compared with continuous flow systems; and c) continuous positive airway pressure with periodic hyperinflations reduced work of breathing (10.7 +/- 9.5 vs. 6.3 +/- 5.7 J/min, p <.05) and dyspnea sensation (1.6 +/- 1.2 vs. 1.1 +/- 0.8 cm, p <.05) increased end-expiratory lung volume (1.6 +/- 0.8 vs. 2.0 +/- 0.9 L, p <.05) and PaO2 (100 +/- 21 vs. 120 +/- 25 torr, p <.05) compared with ventilator continuous positive airway pressure. The continuous flow positive airway pressure systems tested are equally efficient; a ventilator can provide satisfactory continuous positive airway pressure; and the use of periodic hyperinflations during continuous positive airway pressure can improve respiratory function and reduce the work of breathing.
To explore the role of the horizontal orientation of endotracheal tube and neck on bacterial colo... more To explore the role of the horizontal orientation of endotracheal tube and neck on bacterial colonization of the respiratory tract in anesthetized sheep on mechanical ventilation, without use of antibiotics. Prospective animal study. National Institutes of Health research laboratory. Anesthetized, paralyzed, and ventilated sheep. Sheep were randomized into five groups and managed as follows: Group IS contained sheep that were not intubated and were immediately killed. Group HU4 contained six sheep that were mechanically ventilated for 4 hrs, with head and endotracheal tube elevated 30 degrees from horizontal. Group HU72 contained seven sheep that were prone, mechanically ventilated for 72 hrs, and managed the same as group HU4. Groups G and Gf each contained seven sheep that were prone on a lateral body rotation device, mechanically ventilated for 72 hrs, with neck and endotracheal tube horizontal. Group Gf received nasogastric enteral feeding. At the end of the study, sheep were examined postmortem, and a total of 11 tissue samples were taken from the trachea, the five lobar bronchi, and the five lobar parenchyma, for qualitative and quantitative culture. Group HU72 had significant decrease in Pao2/Fio2 and heavy bacterial colonization in all sheep. Groups G and Gf retained excellent lung function; lung bacterial colonization was no different from the IS group. The horizontal orientation of the endotracheal tube and neck, through lateral body rotation, showed no altered airway colonization and maintained excellent gas exchange and lung function in our animal model.
... National Institutes of Health, National Heart Lung and Blood Insitutes, Pulmonary and Critica... more ... National Institutes of Health, National Heart Lung and Blood Insitutes, Pulmonary and Critical Care Medicine Branch, Bethesda, MD; Mauro Panigada, MD. ... 1. Berra L, De Marchi L, Panigada M, et al: Evaluation of continuous aspiration of subglottic secretion in an in vivo study. ...
The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is neg... more The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible. Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI.
The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is neg... more The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible. Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI.
Morbidly obese patients, during anesthesia and paralysis, experience more severe impairment of re... more Morbidly obese patients, during anesthesia and paralysis, experience more severe impairment of respiratory mechanics and gas exchange than normal subjects. The authors hypothesized that positive end-expiratory pressure (PEEP) induces different responses in normal subjects (n = 9; body mass index < 25 kg/m2) versus obese patients (n = 9; body mass index > 40 kg/m2). The authors measured lung volumes (helium technique), the elastances of the respiratory system, lung, and chest wall, the pressure-volume curves (occlusion technique and esophageal balloon), and the intraabdominal pressure (intrabladder catheter) at PEEP 0 and 10 cm H2O in paralyzed, anesthetized postoperative patients in the intensive care unit or operating room after abdominal surgery. At PEEP 0 cm H2O, obese patients had lower lung volume (0.59 +/- 0.17 vs. 2.15 +/- 0.58 l [mean +/- SD], P < 0.01); higher elastances of the respiratory system (26.8 +/- 4.2 vs. 16.4 +/- 3.6 cm H2O/l, P < 0.01), lung (17.4 +/- 4.5 vs. 10.3 +/- 3.2 cm H2O/l, P < 0.01), and chest wall (9.4 +/- 3.0 vs. 6.1 +/- 1.4 cm H2O/l, P < 0.01); and higher intraabdominal pressure (18.8 +/-7.8 vs. 9.0 +/- 2.4 cm H2O, P < 0.01) than normal subjects. The arterial oxygen tension was significantly lower (110 +/- 30 vs. 218 +/- 47 mmHg, P < 0.01; inspired oxygen fraction = 50%), and the arterial carbon dioxide tension significantly higher (37.8 +/- 6.8 vs. 28.4 +/- 3.1, P < 0.01) in obese patients compared with normal subjects. Increasing PEEP to 10 cm H2O significantly reduced elastances of the respiratory system, lung, and chest wall in obese patients but not in normal subjects. The pressure-volume curves were shifted upward and to the left in obese patients but were unchanged in normal subjects. The oxygenation increased with PEEP in obese patients (from 110 +/-30 to 130 +/- 28 mmHg, P < 0.01) but was unchanged in normal subjects. The oxygenation changes were significantly correlated with alveolar recruitment (r = 0.81, P < 0.01). During anesthesia and paralysis, PEEP improves respiratory function in morbidly obese patients but not in normal subjects.
American Journal of Respiratory and Critical Care Medicine, 1999
Mechanical ventilation with plateau pressure lower than 35 cm H2O and high positive end-expirator... more Mechanical ventilation with plateau pressure lower than 35 cm H2O and high positive end-expiratory pressure (PEEP) has been recommended as lung protective strategy. Ten patients with ARDS (five from pulmonary [p] and five from extrapulmonary [exp] origin), underwent 2 h of lung protective strategy, 1 h of lung protective strategy with three consecutive sighs/min at 45 cm H2O plateau pressure, and 1 h of lung protective strategy. Total minute ventilation, PEEP (14.0 +/- 2.2 cm H2O), inspiratory oxygen fraction, and mean airway pressure were kept constant. After 1 h of sigh we found that: (1) PaO2 increased (from 92.8 +/- 18.6 to 137.6 +/- 23.9 mm Hg, p < 0.01), venous admixture and PaCO2 decreased (from 38 +/- 12 to 28 +/- 14%, p < 0.01; and from 52.7 +/- 19.4 to 49.1 +/- 18.4 mm Hg, p < 0.05, respectively); (2) end-expiratory lung volume increased (from 1.49 +/- 0.58 to 1.91 +/- 0.67 L, p < 0.01), and was significantly correlated with the oxygenation (r = 0.82, p < 0.01) and lung elastance (r = 0.76, p < 0.01) improvement. Sigh was more effective in ARDSexp than in ARDSp. After 1 h of sigh interruption, all the physiologic variables returned to baseline. The derecruitment was correlated with PaCO2 (r = 0.86, p < 0.01). We conclude that: (1) lung protective strategy alone at the PEEP level used in this study may not provide full lung recruitment and best oxygenation; (2) application of sigh during lung protective strategy may improve recruitment and oxygenation.
V entilator-associated pneumonia (VAP) is a common infectious complication in patients admitted t... more V entilator-associated pneumonia (VAP) is a common infectious complication in patients admitted to the intensive care unit (ICU) and is associated with substantially increased morbidity, increased duration of mechanical ventilation and length of stay as well as increased mortality (1-3). Prevention of VAP is therefore one of the foremost aims in mechanically ventilated critically ill patients. As immobilization and supine position are accused to be associated with increased risk for VAP, positioning maneuvers to prevent pneumonia have been investigated. Semirecumbent position of 45°a nd prone position have been shown to decrease the risk for VAP (4, 5). Continuous lateral rotation therapy (CLRT), using a specially designed bed, allows rotation of patients in the longitudinal axis from one lateral position to the other over total angles between 60°and 164°. Beneficial mechanisms of continuous ro-tation seem to be reduction of extravascular lung water (6), improvement of ventilation-perfusion relationship (7), and secretolysis with reduction of atelectases (8). Several studies reported a significant reduction in the prevalence of VAP in patients undergoing rotation therapy, irrespective of the rotation angle (9 -20) but they mostly failed to show a beneficial effect on the duration of mechanical ventilation, length of stay, and mortality. Three meta-analyses underlined these results and question the quality of most of the studies (21-23). Regarding the discrepancy between reduced occurrence of VAP and the failure to improve clinical outcome, the authors called for a rigorously conducted, adequately designed trial to overcome the shortcomings of many published studies like inadequate definition and diagnosis of pneumonia and allocation concealment, lack of blinding measures for diagnosis of pneumonia, unre-Objective: To investigate the impact of prophylactic continuous lateral rotation therapy on the prevalence of ventilator-associated pneumonia, duration of mechanical ventilation, length of stay, and mortality in critically ill medical patients.
Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification o... more Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification of this condition could be of interest. The aim of this study was to evaluate whether a modified point-of-care viscoelastic hemostatic assay can detect sepsis-induced impairment of fibrinolysis and to correlate impaired fibrinolysis with morbidity and mortality. This single center observational prospective pilot study was performed in an adult Intensive Care Unit (ICU) of a tertiary academic hospital. Forty consecutive patients admitted to the ICU with severe sepsis or septic shock were included. Forty healthy individuals served as controls. We modified conventional kaolin activated thromboelastography (TEG) adding urokinase to improve assessment of fibrinolysis in real time (UK-TEG). TEG, UK-TEG, plasminogen activator inhibitor (PAI)-1, thrombin-activatable fibrinolysis inhibitor (TAFI), d-dimer, DIC scores and morbidity (rated with the SOFA score) were measured upon ICU admission. Logis...
INTRODUCTION. Veno-venous extracorporeal membrane oxygenation (ECMO) requires blood anticoagulati... more INTRODUCTION. Veno-venous extracorporeal membrane oxygenation (ECMO) requires blood anticoagulation to prevent activation of the coagulation cascade led by the presence of indwelling catheters and the extracorporeal circuit. Anticoagulation is usually achieved with Unfractionated Heparin (UH) infusion; however, variability of the anticoagulation degree and monitoring methods exists among centers [1]. Activated Partial Thromboplastin Time (aPTT) is one of the most frequently used monitoring methods. Thromboelastography (TEG) may be an alternative, point-of-care tool to monitor anticoagulation during extracorporeal membrane oxygenation, but it has been used only anecdotally. OBJECTIVES. To compare anticoagulation monitoring using aPTT, i.e. current clinical practice at our institution, with the reaction time (R) parameter at TEG. METHODS. Thirty-two consecutive patients undergoing femoro-femoral veno-venous ECMO for acute respiratory failure from December 2011 to August 2013 admitted ...
Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilatio... more Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilation, is the most common nosocomial infection in patients with acute respiratory failure. The major mechanism of lower respiratory tract colonization is aspiration of bacteria-colonized secretions from the oropharynx into the lower airways. The hydrostatic pressure of the secretions that collect in the subglottic space, which is the area above the endotracheal tube (ETT) cuff, or aerosolization of bacteria from the secretions collected within the respiratory tubing may facilitate the leakage into the lower airways. Ideally, the elimination of the mechanisms responsible for aspiration would decrease the incidence of VAP. Several preventive measures have been tested in clinical trials with little success.Here we present the results of our efforts to develop novel approaches for the prevention of VAP. Specifically, we found that keeping ventilated patients in a lateral position, which eliminat...
To compare the effect on respiratory function of different continuous positive airway pressure sy... more To compare the effect on respiratory function of different continuous positive airway pressure systems and periodic hyperinflations in patients with respiratory failure. Prospective Hospital intensive care unit. Sixteen intubated patients (eight men and eight women, age 54 +/- 18 yrs, PaO2/FiO2 277 +/- 58 torr, positive end-expiratory pressure 6.2 +/- 2.0 cm H2O). We evaluated continuous flow positive airway pressure systems with high or low flow plus a reservoir bag equipped with spring-loaded mechanical or underwater seal positive end-expiratory pressure valve and a continuous positive airway pressure by a Servo 300 C ventilator with or without periodic hyperinflations (three assisted breaths per minute with constant inspiratory pressure of 30 cm H2O over positive end-expiratory pressure). We measured the respiratory pattern, work of breathing, dyspnea sensation, end-expiratory lung volume, and gas exchange. We found the following: a) Work of breathing and gas exchange were comparable between continuous flow systems; b) the ventilator continuous positive airway pressure was not different compared with continuous flow systems; and c) continuous positive airway pressure with periodic hyperinflations reduced work of breathing (10.7 +/- 9.5 vs. 6.3 +/- 5.7 J/min, p <.05) and dyspnea sensation (1.6 +/- 1.2 vs. 1.1 +/- 0.8 cm, p <.05) increased end-expiratory lung volume (1.6 +/- 0.8 vs. 2.0 +/- 0.9 L, p <.05) and PaO2 (100 +/- 21 vs. 120 +/- 25 torr, p <.05) compared with ventilator continuous positive airway pressure. The continuous flow positive airway pressure systems tested are equally efficient; a ventilator can provide satisfactory continuous positive airway pressure; and the use of periodic hyperinflations during continuous positive airway pressure can improve respiratory function and reduce the work of breathing.
To explore the role of the horizontal orientation of endotracheal tube and neck on bacterial colo... more To explore the role of the horizontal orientation of endotracheal tube and neck on bacterial colonization of the respiratory tract in anesthetized sheep on mechanical ventilation, without use of antibiotics. Prospective animal study. National Institutes of Health research laboratory. Anesthetized, paralyzed, and ventilated sheep. Sheep were randomized into five groups and managed as follows: Group IS contained sheep that were not intubated and were immediately killed. Group HU4 contained six sheep that were mechanically ventilated for 4 hrs, with head and endotracheal tube elevated 30 degrees from horizontal. Group HU72 contained seven sheep that were prone, mechanically ventilated for 72 hrs, and managed the same as group HU4. Groups G and Gf each contained seven sheep that were prone on a lateral body rotation device, mechanically ventilated for 72 hrs, with neck and endotracheal tube horizontal. Group Gf received nasogastric enteral feeding. At the end of the study, sheep were examined postmortem, and a total of 11 tissue samples were taken from the trachea, the five lobar bronchi, and the five lobar parenchyma, for qualitative and quantitative culture. Group HU72 had significant decrease in Pao2/Fio2 and heavy bacterial colonization in all sheep. Groups G and Gf retained excellent lung function; lung bacterial colonization was no different from the IS group. The horizontal orientation of the endotracheal tube and neck, through lateral body rotation, showed no altered airway colonization and maintained excellent gas exchange and lung function in our animal model.
... National Institutes of Health, National Heart Lung and Blood Insitutes, Pulmonary and Critica... more ... National Institutes of Health, National Heart Lung and Blood Insitutes, Pulmonary and Critical Care Medicine Branch, Bethesda, MD; Mauro Panigada, MD. ... 1. Berra L, De Marchi L, Panigada M, et al: Evaluation of continuous aspiration of subglottic secretion in an in vivo study. ...
The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is neg... more The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible. Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI.
The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is neg... more The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible. Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI.
Morbidly obese patients, during anesthesia and paralysis, experience more severe impairment of re... more Morbidly obese patients, during anesthesia and paralysis, experience more severe impairment of respiratory mechanics and gas exchange than normal subjects. The authors hypothesized that positive end-expiratory pressure (PEEP) induces different responses in normal subjects (n = 9; body mass index < 25 kg/m2) versus obese patients (n = 9; body mass index > 40 kg/m2). The authors measured lung volumes (helium technique), the elastances of the respiratory system, lung, and chest wall, the pressure-volume curves (occlusion technique and esophageal balloon), and the intraabdominal pressure (intrabladder catheter) at PEEP 0 and 10 cm H2O in paralyzed, anesthetized postoperative patients in the intensive care unit or operating room after abdominal surgery. At PEEP 0 cm H2O, obese patients had lower lung volume (0.59 +/- 0.17 vs. 2.15 +/- 0.58 l [mean +/- SD], P < 0.01); higher elastances of the respiratory system (26.8 +/- 4.2 vs. 16.4 +/- 3.6 cm H2O/l, P < 0.01), lung (17.4 +/- 4.5 vs. 10.3 +/- 3.2 cm H2O/l, P < 0.01), and chest wall (9.4 +/- 3.0 vs. 6.1 +/- 1.4 cm H2O/l, P < 0.01); and higher intraabdominal pressure (18.8 +/-7.8 vs. 9.0 +/- 2.4 cm H2O, P < 0.01) than normal subjects. The arterial oxygen tension was significantly lower (110 +/- 30 vs. 218 +/- 47 mmHg, P < 0.01; inspired oxygen fraction = 50%), and the arterial carbon dioxide tension significantly higher (37.8 +/- 6.8 vs. 28.4 +/- 3.1, P < 0.01) in obese patients compared with normal subjects. Increasing PEEP to 10 cm H2O significantly reduced elastances of the respiratory system, lung, and chest wall in obese patients but not in normal subjects. The pressure-volume curves were shifted upward and to the left in obese patients but were unchanged in normal subjects. The oxygenation increased with PEEP in obese patients (from 110 +/-30 to 130 +/- 28 mmHg, P < 0.01) but was unchanged in normal subjects. The oxygenation changes were significantly correlated with alveolar recruitment (r = 0.81, P < 0.01). During anesthesia and paralysis, PEEP improves respiratory function in morbidly obese patients but not in normal subjects.
American Journal of Respiratory and Critical Care Medicine, 1999
Mechanical ventilation with plateau pressure lower than 35 cm H2O and high positive end-expirator... more Mechanical ventilation with plateau pressure lower than 35 cm H2O and high positive end-expiratory pressure (PEEP) has been recommended as lung protective strategy. Ten patients with ARDS (five from pulmonary [p] and five from extrapulmonary [exp] origin), underwent 2 h of lung protective strategy, 1 h of lung protective strategy with three consecutive sighs/min at 45 cm H2O plateau pressure, and 1 h of lung protective strategy. Total minute ventilation, PEEP (14.0 +/- 2.2 cm H2O), inspiratory oxygen fraction, and mean airway pressure were kept constant. After 1 h of sigh we found that: (1) PaO2 increased (from 92.8 +/- 18.6 to 137.6 +/- 23.9 mm Hg, p < 0.01), venous admixture and PaCO2 decreased (from 38 +/- 12 to 28 +/- 14%, p < 0.01; and from 52.7 +/- 19.4 to 49.1 +/- 18.4 mm Hg, p < 0.05, respectively); (2) end-expiratory lung volume increased (from 1.49 +/- 0.58 to 1.91 +/- 0.67 L, p < 0.01), and was significantly correlated with the oxygenation (r = 0.82, p < 0.01) and lung elastance (r = 0.76, p < 0.01) improvement. Sigh was more effective in ARDSexp than in ARDSp. After 1 h of sigh interruption, all the physiologic variables returned to baseline. The derecruitment was correlated with PaCO2 (r = 0.86, p < 0.01). We conclude that: (1) lung protective strategy alone at the PEEP level used in this study may not provide full lung recruitment and best oxygenation; (2) application of sigh during lung protective strategy may improve recruitment and oxygenation.
V entilator-associated pneumonia (VAP) is a common infectious complication in patients admitted t... more V entilator-associated pneumonia (VAP) is a common infectious complication in patients admitted to the intensive care unit (ICU) and is associated with substantially increased morbidity, increased duration of mechanical ventilation and length of stay as well as increased mortality (1-3). Prevention of VAP is therefore one of the foremost aims in mechanically ventilated critically ill patients. As immobilization and supine position are accused to be associated with increased risk for VAP, positioning maneuvers to prevent pneumonia have been investigated. Semirecumbent position of 45°a nd prone position have been shown to decrease the risk for VAP (4, 5). Continuous lateral rotation therapy (CLRT), using a specially designed bed, allows rotation of patients in the longitudinal axis from one lateral position to the other over total angles between 60°and 164°. Beneficial mechanisms of continuous ro-tation seem to be reduction of extravascular lung water (6), improvement of ventilation-perfusion relationship (7), and secretolysis with reduction of atelectases (8). Several studies reported a significant reduction in the prevalence of VAP in patients undergoing rotation therapy, irrespective of the rotation angle (9 -20) but they mostly failed to show a beneficial effect on the duration of mechanical ventilation, length of stay, and mortality. Three meta-analyses underlined these results and question the quality of most of the studies (21-23). Regarding the discrepancy between reduced occurrence of VAP and the failure to improve clinical outcome, the authors called for a rigorously conducted, adequately designed trial to overcome the shortcomings of many published studies like inadequate definition and diagnosis of pneumonia and allocation concealment, lack of blinding measures for diagnosis of pneumonia, unre-Objective: To investigate the impact of prophylactic continuous lateral rotation therapy on the prevalence of ventilator-associated pneumonia, duration of mechanical ventilation, length of stay, and mortality in critically ill medical patients.
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