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From Mechanical Ventilation to Intensive Care Medicine: a Challenge &For Bosnia and Herzegovina

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From Mechanical Ventilation to Intensive Care Medicine: a Challenge &For Bosnia and Herzegovina FROM MECHANICAL VENTILATION TO INTENSIVE CARE MEDICINE: A CHALLENGE &FOR BOSNIA AND HERZEGOVINA Guillaume Thiéry1,2,3*, Pedja Kovačević2,4, Slavenka Štraus5, Jadranka Vidović2, Amer Iglica1, Emir Festić6, Ognjen Gajić7 ¹ Medical Intensive Care Unit, Clinical Centre University of Sarajevo, Bolnička , Sarajevo, Bosnia and Herzegovina ² Medical Intensive Care Unit, Clinical Center Banja Luka, Banja Luka, Bosnia and Hercegovina ³ Medical Intensive Care Unit, St Louis Hospital, University Denis Diderot, avenue Claude Vellefaux, Paris, France ⁴ Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Hercegovina 5 Heart Center, Clinical Centre University of Sarajevo, Bolnička , Sarajevo, Bosnia and Herzegovina 6 Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA 7 Division of Pulmonary and Critical Care, Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Mayo Clinic, Rochester, MN, United States * Corresponding author Abstract Intensive care medicine is a relatively new specialty, which was created in the ’s, after invent of mechanical ventilation, which allowed caring for critically ill patients who otherwise would have died. First created for treating mechanically ventilated patients, ICUs extended their scope and care to all patients with life threatening conditions. Over the years, intensive care medicine developed further and became a truly multidisciplinary speciality, encompassing patients from various fi elds of medicine and involving special- ists from a range of base specialties, with additional (subspecialty) training in intensive care medicine. In Bosnia and Herzegovina, the founding of the society of intensive care medicine in , the introduction of non invasive ventilation in , and opening of a multidisciplinary ICUs in Banja Luka and Sarajevo heralded a new age of intensive care medicine. Th e number of admissions, high severity scores and needs for mechanical ventilation during the fi rst several months in the medical ICU in Banja Luka confi rmed the need of these kinds of units in the country. In spite of still suboptimal personnel training, creation of ICUs in Bosnia and Herzegovina may serve as example for other developing countries in the region. However, in order to achieve modern ICU standards and follow European trends toward harmonisation of medicine, Bosnia and Herzegovina needs to take up this challenge by recognizing intensive care medicine as a distinctive specialty, by implementing a specifi c training program and by setting up multidisciplinary ICUs in acute care hospitals. KEY WORDS: intensive care, mechanical ventilation, critical care, non invasive ventilation, developing countries. BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2009; 9 (SUPPLEMENT 1): S69-S76 S GUILLAUME THIÉRY ET AL.: FROM MECHANICAL VENTILATION TO INTENSIVE CARE MEDICINE: A CHALLENGE FOR BOSNIA AND HERZEGOVINA Introduction types of machines were tried out during this period. The Engstrom respirator was then developed, widely From the first attempts of resuscitation to modern used, and became the fi rst respirator that could deliver and sophisticated intensive care medicine, many cen- a predetermined volume at a preset frequency. Th e ef- turies have passed. However, the major development fi ciency of this respirator was subsequently confi rmed in occurred from the ’s. Over the last years, me- Stockholm Hospital in , where patients with po- chanical ventilation and other life sustaining interven- liomyelitis were ventilated with a mortality rate (). tions dramatically improved, and intensive care units Meanwhile, major progress was made in understand- (ICUs) became able to treat patients presenting with ing lung physiology and pathology. Several physi- more and more critically ill conditions. In this review, ologists allowed a better understanding of respiration we would like to describe the parallel history of me- and gas exchanges. Measurements of PCO, pH and chanical ventilation and intensive care medicine, and to oxygen saturation were developed (). Similarly to Ib- point out the current situation of intensive care medi- sen, Astrup gained great experience during the ’s cine in Bosnia and Herzegovina, with special focus on epidemics in Denmark, and subsequently described the main requirements that are necessary in order to the influence of artificial ventilation on modification reach modern standards in intensive care medicine. of pH and PCO. He even reported the risk of over- ventilation, which, years later, became a major issue History of Mechanical Ventilation in mechanical ventilation. During the following two decades, improvements in laboratory measurements Th e early ages helped clinicians evaluate the eff ectiveness of ventila- Th e fi rst experiments of respiratory resuscitation have tion and various physiological conditions such as circu- been reported in the middle of the th century, de- latory collapse, renal function or fl uid balance. In addi- scribing insufflations of air into the lungs through a tion, new knowledge and modern equipment facilitated pipe introduced into the trachea. Between the th safer and more successful use of mechanical ventilation. and the th century, various attempts of mechani- From the ’s, ventilators became more sophisticated, cal insufflations were made, using a positive airway with new modes and the ability to continuously moni- pressure. In the late th, the fi rst ventilators were de- tor various parameters such as pressures, volumes and scribed, namely “tank respirators”: the patient was put fl ows that were actually delivered to the patients. Con- into the ventilator and inspiration was provoked by a sequently, blood gas analysis, ventilator monitoring and negative pressure applied in the ventilator. This sys- other forms of physiologic monitoring were increasingly tem was subsequently developed as “iron lung”, which used to guide ventilator settings. Particularity of respi- was commonly used in the fi rst half of the th century. ratory physiology of mechanically ventilated lungs was Th e emergence of mechanical ventilation in its modern better understood thanks to both research works and sense began in Denmark in the th, when an epidem- daily use of monitoring system at the bedside. In ics of poliomyelitis devastated northern Europe. In , the fi rst description of Acute Respiratory Distress Syn- hundreds of patients were hospitalised in Copenhagen drome (ARDS) was published (), and simultaneously because of respiratory paralysis related to poliomyelitis Positive End Expiratory Pressure (PEEP) was found to and were put in iron lungs. Despite this treatment, al- be an eff ective treatment for severe hypoxemia in ARDS most all patients died. A young anaesthetist, named Dr (). The number of patients successfully treated with Bjorn Ibsen, showed that the addition of an intermittent mechanical ventilation dramatically increased, as did the external positive airway pressure through tracheotomy number of beds dedicated to intensive care medicine. would save lives, and described the fi rst standardizes approach of treatment of respiratory failure, includ- Complications of mechanical ventilation ing tracheal intubation, tracheotomy, and artificial From the ’s however, awareness of the complica- respiration by manual ventilation (-). During sev- tions of invasive mechanical ventilation led to interest eral months, hundreds of medical students, nurses and in less aggressive, potentially less injurious ventilatory physiotherapists spent ours applying manual ventilation support, despite more and more higher acuity of criti- and provided the -hours coverage (-). Th at was the cally ill patients. New ventilator modes were proposed, starting point of mechanical ventilation and modern most of them aiming to improve synchronisation be- intensive care medicine. Because of high requirements tween patient and ventilator, or to increase patient’s in human resources could not be easily filed, several participation in his ventilation, reducing aggressive- S BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2009; 9 (SUPPLEMENT 1): S70-S76 GUILLAUME THIÉRY ET AL.: FROM MECHANICAL VENTILATION TO INTENSIVE CARE MEDICINE: A CHALLENGE FOR BOSNIA AND HERZEGOVINA ness of fully controlled ventilation. The most impor- patients, there is a demonstrated benefit in terms of tant deleterious effect of mechanical ventilation was intubation rate, incidence of hospital acquired infec- described in by Didier Dreyfuss who showed tion, duration of stay in the ICU and the hospital, and that excessive volume insuffl ated could seriously dam- finally mortality (-). As a result, the use of NIV age the lung (). Th is phenomenon was subsequently dramatically increased over the years, and has become called Ventilator Induced Lung Injury (VILI) () and the first line of treatment in these indications (). led a complete reappraisal of ventilation strategies by the end of the ’s (), in which the reduction of the History of Intensive Care Medicine tidal volume and the airway pressure was a priority. Cli- nicians soon recognized that short term acceptance of By the end of the ’s, anaesthesia began to develop abnormal blood gas analysis (“permissive hypercapnia”) as an entire specialty. Th e Danish school of anaesthesia is tolerated by mechanically ventilated patients (). was one of the most famous, for both education and or- However, despite improvement of respiratory care ganisation of care. In , Copenhagen hospital stated long term exposure to ventilarory support was shown that anaesthetists
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