Automated versus non-automated weaning for reducing the duration of mechanical ventilation in critically ill adults & children (Review)

Background Automated closed loop systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. This review was originally published in 2013 with an update published in 2014. Objectives The primary objective for this review was to compare the total duration of weaning from mechanical ventilation, defined as the time from study randomization to successful extubation (as defined by study authors), for critically ill ventilated patients managed with an automated weaning system versus no automated weaning system (usual care). Secondary objectives for this review were to determine differences in the duration of ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), mortality, and adverse events related to early or delayed extubation with the use of automated weaning systems compared to weaning in the absence of an automated weaning system. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (OvidSP) (1948 to September 2013); EMBASE (OvidSP) (1980 to September 2013); CINAHL (EBSCOhost) (1982 to September 2013); and the Latin American and Caribbean Health Sciences Literature (LILACS). Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. The original search was run in August 2011, with database auto-alerts up to August 2012. Selection criteria We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an ICU. Data collection and analysis Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. Main results We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I2 = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk. Authors' conclusions Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Cyclic nanoindentation and nano-impact fatigue characterisation of functionally graded TiN/TiNi shape memory film

This paper investigates the mechanism of nanoscale fatigue of functionally graded TiN/TiNi films using nano-impact and multiple-loading-cycle nanoindentation tests. The functionally graded films were deposited on silicon substrate, in which TiNi films maintain shape memory and pseudo elastic behavior, while a modified TiN surface layer provides tribological and anti-corrosion properties. Nanomechanical tests were performed to comprehend the localized film performance and failure modes of the functionally graded film using NanoTestTM equipped with Berkovich and conical indenter between 100 μN to 500 mN loads. The loading mechanism and load history are critical to define film failure modes (i.e. backward depth deviation) including the shape memory effect of the functionally graded layer. The results are sensitive to the applied load, loading type (e.g. semi-static, dynamic) and probe geometry. Based on indentation force-depth profiles, depth-time data and post-test surface observations of films, it is concluded that the shape of the nanoindenter is critical in inducing the localized indentation stress and film failure, including shape recovery at the lower load range. Elastic-plastic finite element (FE) simulation during nanoindentation loading indicated that the location of subsurface maximum stress near the interface influences the backward depth deviation type of film failure. A standalone, molecular dynamics simulation was performed with the help of a long range potential energy function to simulate the tensile test of TiN nanowire with two different aspect ratios to investigate the theory of its failure mechanism.

To be inside someone else's dream: On Music for Sleeping &amp; Waking Minds

Music for Sleeping &amp; Waking Minds (2011-2012) is a new,overnight work in which four performers fall asleep while wearing custom designed EEG sensors which monitor their brainwave activity. The data gathered from the EEG sensors is applied in real time to different audio and image signal processing functions, resulting in continuously evolving multichannel sound environment and visual projection. This material serves as an audiovisual description of the individual and collective neuro physiological state of the ensemble. Audiences are invited to experience the work in different states of attention: while alert and asleep, resting and awakening.