Richard Branson

Richard Branson
University of Cincinnati | UC · Surgery - Trauma & Critical Care

MSc RRT

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406
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Introduction
Skills and Expertise

Publications

Publications (406)
Article
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strate...
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Full-text available
Infection with the severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) in select individuals results in viral sepsis, pneumonia and hypoxemic respiratory failure, collectively known as coronavirus disease 2019 (COVID-19). In the early months of the pandemic the combination of novel disease presentation, enormous surges of critically ill pa...
Article
Background The COVID-19 pandemic has challenged health care professionals, especially those working in intensive care units (ICUs). Objectives To explore critical care nurses’ experiences with and perceptions of the COVID-19 pandemic during the early phases of the pandemic. Methods Data were from national surveys conducted during March and April...
Article
Background: The primary goal of this study was to demonstrate that endotracheal tubes coated with antimicrobial lipids plus mucolytic or antimicrobial lipids with antibiotics plus mucolytic would significantly reduce pneumonia in the lungs of pigs after 72 hours of continuous mechanical ventilation compared to uncoated controls. Materials and met...
Article
The state of California, in the United States of America, has a population of nearly 40 million people and is the 5 th largest economy in the world. During the COVID-19 (Coronavirus Disease) pandemic in 2020-2021, the state experienced a medical surge that stressed its sophisticated healthcare and public health system. During this period, ventilato...
Article
COVID-19 resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a pandemic of respiratory failure previously unencountered. Early in the pandemic, concentrated infections in high-density population cities threatened to overwhelm health systems, and ventilator shortages were predicted. An early proposed solution...
Article
This document summarizes the work of the Chronic Obstructive Pulmonary Disease (COPD) Technical Expert Panel working group. For patients with COPD, the most pressing current coverage barriers identified were onerous diagnostic requirements focused on oxygenation (rather than ventilation), and difficulty obtaining bilevel devices with backup rate ca...
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Background: The COVID-19 pandemic has led to an increased demand for mechanical ventilators and concerns of a ventilator shortage. Several groups have advocated for 1 ventilator to ventilate 2 or more patients in the event of such a shortage. However, differences in patient lung mechanics could make sharing a ventilator detrimental to both patient...
Article
Resuscitation of the critically ill or injured is a significant and complex task in any setting, often complicated by environmental influences. Hypothermia is one of the components of the "Triad of Death" in trauma patients. Devices for warming IV fluids in the austere environment must be small and portable, able to operate on battery power, warm f...
Article
Somewhere between 30 to 89% of patients with COVID-19 admitted to a critical care unit require invasive mechanical ventilation. Concern over the lack of adequate numbers of critical care ventilators to meet this demand led the United States Food and Drug Administration to authorize the use of anesthesia machines as critical care ventilators. The us...
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Background: Early in the COVID-19 pandemic, there was serious concern that the United States (US) would encounter a short fall of mechanical ventilators. In response, the US government, utilizing the Defense Production Act ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities...
Article
Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited.Target Audience: Patients with COPD, clinicians who care for them, and policy makers.Methods: We summarized evidence addressing...
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Importance: Recent reports identify that among hospitalized coronavirus disease 2019 patients, 30% require ICU care. Understanding ICU resource needs remains an essential component of meeting current and projected needs of critically ill coronavirus disease 2019 patients. Objectives: This study queried U.S. ICU clinician perspectives on challeng...
Article
Transport of critically ill patients within and between hospitals is a common undertaking in an effort to improve patient outcomes. Intrahospital transports are frequently conducted to aid in diagnosis through advanced imaging techniques or to allow image-guided procedures. Interhospital transport is most frequently conducted to bring patients to s...
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Introduction: The use of shared ventilation, or the simultaneous support of multiple patients connected in parallel to a single mechanical ventilator, is receiving considerable interest for addressing the severe shortage of mechanical ventilators available during the novel coronavirus pandemic (COVID-19). In this paper we highlight the potentially...
Article
Introduction: Intrathoracic pressure regulation (ITPR) can be utilized to enhance venous return and cardiac preload by inducing negative end expiratory pressure in mechanically ventilated patients. Previous preclinical studies have shown increased mean arterial pressure (MAP) and decreased intracranial pressure (ICP) with use of an ITPR device. Th...
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Background: The overwhelming demand for mechanical ventilators due to COVID-19 has stimulated interest in using one ventilator for multiple patients (multiplex ventilation). Despite a plethora of information on the Internet, there is little supporting evidence and no human studies. The risk of multiplex ventilation is that ventilation and PEEP eff...
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Prediction models aim to use available data to predict a health state or outcome that has not yet been observed. Prediction is primarily relevant to clinical practice, but is also used in research, and administration. While prediction modeling involves estimating the relationship between patient factors and outcomes, it is distinct from casual infe...
Chapter
Aeromedical evacuation of the critically ill and injured patient requires careful consideration and preparation long before the mission takes place. Key elements are selection of the appropriately skilled staff, good communication, equipment adequate for the needs of the patient, and a healthy respect for the task at hand. Mechanical ventilation ad...
Article
Introduction Adequate oxygenation is one of the primary goals of mechanical ventilation. Maintenance of adequate oxygenation and prevention of hypoxemia are the primary goals for the battlefield casualty, but military operations have unique concerns. In military operations, oxygen is a limited resource. A portable oxygen concentrator has the advant...
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Study objective: The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. Methods: We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in t...
Article
Closed loop control of mechanical ventilation is routine and operates behind the ventilator interface. Reducing caregiver interactions is neither an advantage for the patient or the staff. Automated systems causing lack of situational awareness of the intensive care unit are a concern. Along with autonomous systems must come monitoring and displays...
Article
Long-term oxygen therapy (LTOT) at home has been demonstrated to improve survival in patients with COPD and severe resting hypoxemia. Support for LTOT is based on 2 landmark trials published nearly 4 decades ago. These results form the basis for reimbursement and prescription of LTOT to this day. Recent work has demonstrated no outcome benefit of L...
Article
Background: It is unknown whether ketamine administered via patient-controlled analgesia (PCA) provides adequate analgesia while reducing opioid consumption in the traumatically injured patient. Differences in opioid consumption, pain scores, and adverse effects between ketamine and hydromorphone PCA were studied. Materials and methods: This is...
Article
Background: Safe and effective delivery of inhaled nitric oxide (INO) requires the appropriate interface of ventilator and INO delivery device. Methods: We compared INO delivery using four configurations with the Transport Sinusoidal Bronchotron® and INOmax DSIR Plus® in a lung model. Ventilator settings and lung model values were held constant....
Article
Background: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. Methods: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest...
Article
Background: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) study evaluated the effects of plasma and platelets on hemostasis and mortality after hemorrhage. The pulmonary consequences of resuscitation strategies that mimic whole blood, remain unknown. Methods: A secondary analysis of the PROPPR study was performed. Injured...
Article
Introduction Devices may forgo US military air worthiness and safety testing in an attempt to expedite the availability of critical assets such as mechanical ventilators with a waiver for one-time use in extenuating circumstances. Methods We evaluated two Intensive Care Unit (ICU) level ventilators: Drager Evita XL and Puritan Bennett (PB) 840 in...
Article
Background: This document provides evidence-based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS). Methods: A multidisciplinary panel conducted systematic reviews and metaanalyses of the relevant research and applied Grading of Recommendations, Assessment, Develo...
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Background: Noninvasive monitoring of hemoglobin (SpHgb) via pulse oximetry has the potential to alert caregivers to blood loss. Previous studies have demonstrated that changes in oxygenation may impact accuracy. Methods: Twenty normal volunteers were monitored using SpHgb at sea level, during ascent to 14,000 feet, at 14,000 feet with 100% oxyg...
Article
Background: Successful mechanical ventilation requires that the airway be controlled by an endotracheal tube (ETT) with an inflatable cuff to seal the airway. Aeromedical evacuation represents a unique challenge in which to manage ETT cuffs. We evaluated three methods of automatic ETT cuff pressure adjustment during changes in altitude in an altit...
Article
In Reply > That which we call a rose, By any other name would smell as sweet. > > —William Shakespeare Chatburn finds fault in our description of intermittent mandatory ventilation (IMV),[1][1] as we primarily discuss IMV as first described by Downs.[2][2] That is, a preset mandatory rate with
Article
Objectives: The optimal amount of oxygen to deploy with pararescue personnel for combat casualty care is currently unknown. The purpose of this prospective observational trial was to determine the proportion of trauma patients requiring supplemental oxygen, whether high or low flow rates were needed, and to evaluate associations between injury cha...
Article
Outcomes: The time difference when SpO2/FiO2 <250 and RscVent initiation was 4.7 ± 0.6 hr and 0.2 ± 0.1 hr, SOC and SOS, respectively (p<0.001). Oxygen responsiveness after RscVent, defined as: SpO2/FiO2 > 250 occurred in 4/7, SOS and 0/7, SOC. At 48 hr the SpO2/FiO2 ratio was 104 ± 5 SOC versus 228 ± 59 SOS, p = 0.036. Ventilatory compliance and...
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Oxygen is both lifesaving and toxic. Appropriate use of oxygen aims to provide a balance between the two effects. Although local oxygen toxicity to the lung is well accepted, recent evidence has called into question the negative consequences of hyperoxemia in other organ beds. Hyperoxia following cardiac arrest, traumatic brain injury, and stroke h...
Article
Intermittent mandatory ventilation (IMV) was introduced nearly 50 years ago. Despite the initial fanfare and early adoption by many, the role of IMV continues to be questioned. The use of small tidal volumes complicates the application of IMV, and issues with work of breathing, weaning and lack of clear advantages have many calling for a moratorium...
Article
In the current theater of operation, medical devices are often shipped and stored at ambient conditions. The effect of storage at hot and cold temperature extremes on ventilator performance is unknown. We evaluated three portable ventilators currently in use or being evaluated for use by the Department of Defense (731, Impact Instrumentation; T1, H...
Article
Background: Addition of an oxygen concentrator into a control loop furthers previous work in autonomous control of oxygenation. Software integrates concentrator and ventilator function from a single control point, ensuring maximum efficiency by placing a pulse of oxygen at the beginning of the breath. We sought to verify this system. Methods: In...
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Oxygen cylinders are heavy and present a number of hazards, and liquid oxygen is too heavy and cumbersome to be used in far forward environments. Portable oxygen concentrators (POCs) and chemical oxygen generators (COGs) have been proposed as a solution. We evaluated 3 commercially available POCs and 3 COGs in a laboratory setting. Altitude testing...
Article
The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care....
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Some types of public health emergencies could result in large numbers of patients with respiratory failure who need mechanical ventilation. Federal public health planning has included needs assessment and stockpiling of ventilators. However, additional federal guidance is needed to assist states in further allocating federally supplied ventilators...
Article
Background: Hypobaric hypoxemia is a well-known risk of aeromedical evacuation (AE). Validating patients as safe to fly includes assessment of oxygenation status as well as oxygen-carrying capability (hemoglobin). The incidence and severity of hypoxemia during AE of noncritically injured casualties have not been studied. Methods: Subjects deemed...
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Aerosolized medications are used as airway clearance therapy to treat a variety of airway diseases. These guidelines were developed from a systematic review with the purpose of determining whether the use of these medications to promote airway clearance improves oxygenation and respiratory mechanics, reduces ventilator time and ICU stay, and/or res...
Article
Closed-loop controllers (CLCs) embedded within portable mechanical ventilators may allow for autonomous weaning. The ability of CLCs to maintain adequate oxygenation in the setting of hemorrhage and lung injury is unknown. We hypothesized that a portable ventilator with a CLC for inspired fraction of oxygen (FIO2) could provide oxygenation in a por...
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Hypoxemia secondary to reduced barometric pressure is a complication of ascent to altitude. We designed a study to compare the reversal of hypobaric hypoxemia at 14,000 ft with continuous flow oxygen from a cylinder and pulsed dose oxygen from a portable concentrator. There were 30 healthy volunteers who were randomized to one of three study groups...
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To determine the alterations in intracranial pressure (ICP) during U. S. Air Force Critical Care Air Transport Team transport of critically injured warriors with ICP monitoring by intraventricular catheter (IVC). Patients with an IVC following traumatic brain injury requiring aeromedical evacuation from Bagram to Landstuhl Regional Medical Center w...
Article
Obtaining IV access for fluid administration is a critical step in treating hemorrhage. However, expertise, supplies and personnel to accomplish this task can be delayed or even absent in austere environments. An alternative approach that can 'buy time' and improve circulation when iv fluids are absent is needed. Preclinical studies show that intra...
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To the Editor: We read with interest the paper by Fisher et al[1][1] regarding the methods for securing endotracheal tubes. The authors should be congratulated for a carefully performed experiment in a model of the head and upper airway. We noted the increase in pressure exerted by the
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BACKGROUND Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are invo...
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Background: Ascent to altitude results in the expansion of gases in closed spaces. The management of overinflation of the endotracheal tube (ETT) cuff at altitude is critical to prevent mucosal injury. Methods: We continuously measured ETT cuff pressures during a Critical Care Air Transport Team training flight to 8,000-ft cabin pressure using f...
Article
Background: Monitoring for acute blood loss is critical in surgical patients, and delays in identifying hemorrhage can result in poor outcomes. The current standard of care for monitoring patients at risk for bleeding is serial measurement of hemoglobin (Hgb) by standard laboratory complete blood count (CBC). Point-of-care testing (i.e., iSTAT) ca...
Article
Background: Aeromedical transport of critically ill patients requires continued, accurate performance of equipment at altitude. Changes in barometric pressure can affect the performance of mechanical ventilators calibrated for operation at sea level. Deploying ventilators that can maintain a consistent tidal volume (VT) delivery at various altitud...
Article
Purpose: Early ambulation in the ventilated patient is gaining wider acceptance. We evaluated a new portable (1 lb), gas powered, volume ventilator designed for NIV via a proprietary nasal pillows interface (Breathe Technologies, CA). Methods: We developed a model to approximate a patient's nose, upper airway and trachea. The model was connected...
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Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-asso...
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Background: Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individu...
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Full-text available
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-asso...
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Full-text available
Background: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection...
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Importance Advances in the care of the injured patient are perhaps the only benefit of military conflict. One of the unique aspects of the military medical care system that emerged during Operation Iraqi Freedom and Operation Enduring Freedom has been the opportunity to apply existing civilian trauma system standards to the provision of combat cas...