Translate this page to:
Choose Language…
In JoVE (1)
Other Publications (39)
- Canadian Respiratory Journal : Journal of the Canadian Thoracic Society
- Critical Care (London, England)
- Critical Care Medicine
- JAMA : the Journal of the American Medical Association
- Critical Care (London, England)
- Critical Care (London, England)
- Clinics in Chest Medicine
- Critical Care Medicine
- BMJ (Clinical Research Ed.)
- Critical Care Medicine
- Critical Care Medicine
- The New England Journal of Medicine
- The New England Journal of Medicine
- JAMA : the Journal of the American Medical Association
- American Journal of Respiratory and Critical Care Medicine
- Journal of Intensive Care Medicine
- Critical Care Medicine
- JAMA : the Journal of the American Medical Association
- Critical Care (London, England)
- Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie
- The New England Journal of Medicine
- AACN Advanced Critical Care
- Critical Care (London, England)
- Critical Care Medicine
- Intensive Care Medicine
- Archives of Physical Medicine and Rehabilitation
- Critical Care Medicine
- BMJ (Clinical Research Ed.)
- American Journal of Medical Quality : the Official Journal of the American College of Medical Quality
- Critical Care Medicine
- JAMA : the Journal of the American Medical Association
- JAMA : the Journal of the American Medical Association
- Journal of Critical Care
- Respiratory Care
- Critical Care Medicine
- Critical Care Medicine
- JAMA : the Journal of the American Medical Association
- Critical Care Medicine
- Journal of Clinical Epidemiology
Articles by Eddy Fan in JoVE
JoVE Clinical and Translational Medicine
Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients
1Outcomes After Critical Illness and Surgery (OACIS) Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 2Critical Care Physical Medicine and Rehabilitation Program, Johns Hopkins Hospital, 3Department of Physical Medicine and Rehabilitation, Johns Hopkins University, 4Department of Rehabilitation Services, University of Maryland Medical System
Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.
Other articles by Eddy Fan on PubMed
West Nile Virus Infection in the Intensive Care Unit: a Case Series and Literature Review
West Nile virus (WNV) is a rapidly spreading infectious disease in North America. Critical care issues related to WNV are not well described.
Albumin in Critical Care: SAFE, but Worth Its Salt?
Intravascular fluid therapy is a common critical care intervention. However, the optimal type of resuscitation fluid, crystalloid or colloid, remains controversial. Despite the many theoretical benefits of human albumin administration in critically ill patients, there has been little evidence to support its widespread clinical use. Previous systematic reviews have led to conflicting results regarding the safety and efficacy of albumin. The recently reported Saline versus Albumin Evaluation study has provided conclusive evidence that 4% albumin is as safe as saline for resuscitation, although no overall benefit of albumin use was seen. Subgroup analysis of the albumin-treated group revealed a trend towards decreased mortality in patients with septic shock, and a trend towards increased mortality in trauma patients, especially those with traumatic brain injury. The results of these subgroups, as well as the use of higher albumin concentrations and other synthetic colloids (dextrans, starches), require rigorous evaluation in clinical trials. Finally, the Saline versus Albumin Evaluation trial represents a methodological milestone in critical care medicine, due to its size, its efficient trial design, and its logistical coordination. Future studies are still required, however, to establish a therapeutic niche for albumin and other colloids.
High-frequency Oscillatory Ventilation and Adjunctive Therapies: Inhaled Nitric Oxide and Prone Positioning
To review the use of high-frequency oscillatory ventilation (HFOV) with adjunctive therapies (inhaled nitric oxide [iNO] and prone positioning [PP]) in adult patients with acute respiratory distress syndrome (ARDS).
Ventilatory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome
The acute lung injury and acute respiratory distress syndrome are critical illnesses associated with significant morbidity and mortality. Mechanical ventilation is the cornerstone of supportive therapy. However, despite several important advances, the optimal strategy for ventilation and adjunctive therapies for patients with acute lung injury and acute respiratory distress syndrome is still evolving.
Outcomes of Interfacility Critical Care Adult Patient Transport: a Systematic Review
We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.
Pro-con Debate: Steroid Use in ACTH Non-responsive Septic Shock Patients with High Baseline Cortisol Levels
Steroid use in critically ill, vasopressor-dependant, septic patients has gained increased acceptance in recent years with the publication of encouraging data. However, with renewed interest and/or attention comes increased debate and analysis. As a result, it is not surprising to find that there is still significant controversy with regards to the role of steroids in many patients. In this article, two expert groups debate the role of steroid use in a septic shock patient with arguably no clear evidence of adrenal insufficiency.
New Modalities of Mechanical Ventilation: High-frequency Oscillatory Ventilation and Airway Pressure Release Ventilation
Management of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) is largely supportive, with the use of mechanical ventilation being a central feature. Recent advances in the understanding of ALI/ARDS and mechanical ventilation have revealed that lung-protective ventilation strategies may attenuate ventilator-associated lung injury and improve patient morbidity/mortality. High-frequency oscillatory ventilation and airway pressure release ventilation are two novel alternative modes of ventilation that theoretically fulfill the principles of lung protection and may offer an advantage over conventional ventilation for ALI/ARDS.
Informed Consent in the Critically Ill: a Two-step Approach Incorporating Delirium Screening
Sedation-agitation and delirium are common in critically ill patients and may be important barriers to informed consent. We describe a two-step process for informed consent and evaluate the natural history of patients' competency by repeated application of this process during their hospitalization.
Patient and Intensive Care Unit Organizational Factors Associated with Low Tidal Volume Ventilation in Acute Lung Injury
Barriers to evidence-based practice are not well understood. Within the intensive care unit (ICU) setting, low tidal volume ventilation (LTVV) in patients with acute lung injury (ALI) significantly decreases mortality. However, LTVV has not achieved widespread adoption.
Recruitment Maneuvers for Acute Lung Injury: a Systematic Review
There are conflicting data regarding the safety and efficacy of recruitment maneuvers (RMs) in patients with acute lung injury (ALI).
Review of a Large Clinical Series: Sedation and Analgesia Usage with Airway Pressure Release and Assist-control Ventilation for Acute Lung Injury
Our objective was to compare sedative and analgesic doses, agents, and sedation status in patients with airway pressure release ventilation (APRV) versus assist-control (AC) ventilation on the first day after acute lung injury diagnosis.
Inhaled Corticosteroids in Patients with Stable Chronic Obstructive Pulmonary Disease: a Systematic Review and Meta-analysis
Recent studies of inhaled corticosteroid (ICS) therapy for managing stable chronic obstructive pulmonary disease (COPD) have yielded conflicting results regarding survival and risk of adverse events.
ICU Staffing and Patient Outcomes: More Work Remains
Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. Cooke and colleagues investigated this hypothesis in a cohort of 759 acute lung injury patients in 23 ICUs in King County, Washington, USA. Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.
Critical Care Services in Ontario: a Survey-based Assessment of Current and Future Resource Needs
In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada.
Critical Illness Neuromyopathy and Muscle Weakness in Patients in the Intensive Care Unit
Neuromuscular complications of critical illness are common and can be severe and persistent in some patients. Neuromyopathy from critical illness and disuse atrophy from prolonged immobility contribute to muscle weakness acquired while in the intensive care unit. Although various risk factors (eg, severity of illness, corticosteroids, neuromuscular blocking agents) have been implicated in critical illness neuromyopathy (CINM), the evidence supporting these associations is inconsistent. Hyperglycemia may be an important risk factor for CINM, with tight glycemic control through intensive insulin therapy reducing the incidence of CINM. Early mobility in the intensive care unit may minimize disuse atrophy and possibly CINM, through exercise training and its anti-inflammatory effects. Although emerging data have demonstrated the safety, feasibility, and benefit of early mobility in critically ill patients, randomized controlled trials are needed to thoroughly evaluate its potential benefits on patients' muscle strength, physical function, and quality of life. Future studies are needed to elucidate the multiple mechanisms by which immobility, CINM, and other aspects of critical illness lead to muscle loss and neuromuscular dysfunction.
Bench-to-bedside Review: Mobilizing Patients in the Intensive Care Unit--from Pathophysiology to Clinical Trials
As the mortality from critical illness has improved in recent years, there has been increasing focus on patient outcomes after hospital discharge. Neuromuscular weakness acquired in the intensive care unit (ICU) is common, persistent, and often severe. Immobility due to prolonged bed rest in the ICU may play an important role in the development of ICU-acquired weakness. Studies in other patient populations have demonstrated that moderate exercise is beneficial in altering the inflammatory milieu associated with immobility, and in improving muscle strength and physical function. Recent studies have demonstrated that early mobility in the ICU is safe and feasible, with a potential reduction in short-term physical impairment. However, early mobility requires a significant change in ICU practice, with reductions in heavy sedation and bed rest. Further research is required to determine whether early mobility in the ICU can improve patients' short-term and long-term outcomes.
Technology to Enhance Physical Rehabilitation of Critically Ill Patients
Neuromuscular complications after critical illness are common and can be severe and persistent. To ameliorate complications, there is growing interest in starting physical medicine and rehabilitation therapy immediately after physiologic stabilization. The introduction of physical medicine and rehabilitation-related technology into the intensive care unit may help facilitate delivery of this therapy.
Inter-rater Reliability of Manual Muscle Strength Testing in ICU Survivors and Simulated Patients
The goal of the paper is to determine inter-rater reliability of trained examiners performing standardized strength assessments using manual muscle testing (MMT). DESIGN, SUBJECTS, AND SETTING: The authors report on 19 trainees undergoing quality assurance within a multi-site prospective cohort study.
Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory Failure: a Quality Improvement Project
To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay.
Human Immunodeficiency Virus Infection and Hospital Mortality in Acute Lung Injury Patients
To evaluate the impact of human immunodeficiency virus infection on hospital mortality in patients with acute lung injury and to evaluate predictors of mortality among acute lung injury patients with human immunodeficiency virus.
Monitoring and Reducing Central Line-associated Bloodstream Infections: a National Survey of State Hospital Associations
Central line-associated bloodstream infections (CLABSIs) acquired in health care institutions are common and costly. A novel monitoring and prevention program dramatically reduced CLABSIs across one state. The extent to which other states have adopted similar efforts is unknown. State hospital associations were surveyed regarding their efforts to address these infections. All 50 responding associations endorsed the importance of improving patient safety, health care quality, or health care-associated infections. Although 42 (84%) cited CLABSIs as a priority, only 11 (22%) provided statewide CLABSI rates. CLABSI programs were active in 6 (12%) states, and an additional 7 (14%) states were planning programs. Barriers identified included a lack of coordinated priorities, limited infrastructure, and inadequate resources. Although associations support efforts to improve health care quality, including CLABSI prevention, most lack coordinated statewide monitoring and prevention programs. A national collaborative to address CLABSIs may reduce these infections while building capacity to improve other aspects of health care quality.
How to Use an Article About Quality Improvement
Quality improvement (QI) attempts to change clinician behavior and, through those changes, lead to improved patient outcomes. The methodological quality of studies evaluating the effectiveness of QI interventions is frequently low. Clinicians and others evaluating QI studies should be aware of the risk of bias, should consider whether the investigators measured appropriate outcomes, should be concerned if there has been no replication of the findings, and should consider the likelihood of success of the QI intervention in their practice setting and the costs and possibility of unintended effects of its implementation. This article complements and enhances existing Users' Guides that address the effects of interventions--Therapy, Harm, Clinical Decision Support Systems, and Summarizing the Evidence guides--with an emphasis on issues specific to QI studies. Given the potential for widespread implementation of QI interventions, there is a need for robust study methods in QI research.
Therapies for Refractory Hypoxemia in Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome (ARDS) is a common and severe form of acute lung injury, resulting from both direct (eg, pneumonia) and indirect (eg, sepsis) pulmonary insults. It is a common cause of admission to the intensive care unit due to hypoxemic respiratory failure requiring mechanical ventilation, and is associated with significant morbidity and mortality. In some patients, ARDS leads to the development of life-threatening refractory hypoxemia. In these patients, physicians may consider a number of therapies (eg, recruitment maneuvers, prone positioning, inhaled nitric oxide, high-frequency oscillatory ventilation, extracorporeal membrane oxygenation) to alleviate hypoxemia in patients unable to maintain reasonable oxygenation while being supported with conventional mechanical ventilation. Although these strategies have demonstrated improved oxygenation with their use, their impact on patient-important outcomes (eg, mortality) remains unproven. However, in the minority of patients with ARDS and refractory hypoxemia, institution of these therapies may be considered on a case-by-case basis. Future studies are needed to elucidate the efficacy of these therapies on outcomes in patients with severe ARDS and refractory hypoxemia.
Rehabilitation Therapy and Outcomes in Acute Respiratory Failure: an Observational Pilot Project
The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation.
Higher PEEP in Patients with Acute Lung Injury: a Systematic Review and Meta-analysis
Studies of ventilation strategies that included higher PEEP in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) have yielded conflicting results.
Short-term Mortality Prediction for Acute Lung Injury Patients: External Validation of the ARDSNet Prediction Model
OBJECTIVE:: An independent cohort of patients with acute lung injury was used to evaluate the external validity of a simple prediction model for short-term mortality previously developed using data from ARDS Network (ARDSNet) trials. DESIGN, SETTING, AND PATIENTS:: Data for external validation were obtained from a prospective cohort study of patients with acute lung injury from 13 intensive care units at four teaching hospitals in Baltimore, MD. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Of the 508 nontrauma, patients with acute lung injury eligible for this analysis, 234 (46%) died inhospital. Discrimination of the ARDSNet prediction model for inhospital mortality, evaluated by the area under the receiver operator characteristic curves, was 0.67 for our external validation data set vs. 0.70 and 0.68 using Acute Physiology and Chronic Health Evaluation II and the ARDSNet validation data set, respectively. In evaluating calibration of the model, predicted vs. observed inhospital mortality for the external validation data set was similar for both low-risk (ARDSNet model score = 0) and high-risk (score = 3 or 4+) patient strata. However, for intermediate-risk (score = 1 or 2) patients, observed inhospital mortality was substantially higher than predicted mortality (25.3% vs. 16.5% and 40.6% vs. 31.0% for score = 1 and 2, respectively). Sensitivity analyses limiting our external validation data set to only those patients meeting the ARDSNet trial eligibility criteria and to those who received mechanical ventilation in compliance with the ARDSNet ventilation protocol did not substantially change the model's discrimination or improve its calibration. CONCLUSIONS:: Evaluation of the ARDSNet prediction model using an external acute lung injury cohort demonstrated similar discrimination of the model as was observed with the ARDSNet validation data set. However, there were substantial differences in observed vs. predicted mortality among intermediate-risk patients with acute lung injury. The ARDSNet model provided reasonable, but imprecise, estimates of predicted mortality when applied to our external validation cohort of patients with acute lung injury.
Short-term Mortality Prediction for Acute Lung Injury Patients: External Validation of the Acute Respiratory Distress Syndrome Network Prediction Model
An independent cohort of patients with acute lung injury was used to evaluate the external validity of a simple prediction model for short-term mortality previously developed using data from Acute Respiratory Distress Syndrome Network (ARDSNet) trials.
Repeated Attempts Using Different Strategies Are Important for Timely Contact with Study Participants
To study the effect of different mail- and phone-based strategies, along with patient- and research-related factors, on the time to contact with research participants.
