Critical care nursing quarterly
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New management options for acute respiratory failure aim at avoiding ventilator-induced lung injury while maintaining adequate gas exchange. Selected approaches examined in this article include methods to augment carbon dioxide elimination with tracheal gas insufflation, venovenous extracorporeal carbon dioxide removal, and intravascular oxygenation. Improving oxygenation can be accomplished by judicious use of positive end-expiratory pressure, venoarterial extracorporeal membrane oxygenation, and pharmacologic intervention with inhaled nitric oxide.
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There are two major goals of critical care: (1) to save those with a chance to live and (2) to help patients who are dying have a peaceful and dignified death. If reversal of the disease process is not possible and the patient is experiencing substantial pain and suffering, goals need to be reviewed and potentially redefined. These new goals may be to remove unwanted or nonbeneficial therapy, to provide death with dignity, and to support the family. This article details aspects of the decision-making process regarding withdrawal of mechanical ventilation, including ethical principles; decision-making for autonomous patients and non-autonomous patients; advance directives; planning withdrawal of support; terminal weaning methods; patient comfort; family support; and future directions for research, practice, and education.
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One of the many challenges in the management of the patient with adult respiratory distress syndrome is optimal application of mechanical ventilation. Pressure controlled-inverse ratio ventilation has surfaced as a possible alternative to conventional ventilation for patients affected by this condition. In pressure controlled-inverse ratio ventilation, the conventional inspiratory-to-expiratory ratio is reversed, allowing the inspiratory phase to lengthen with an accompanying increase in mean airway pressure. When carefully applied, mean airway pressure adjustments can be manipulated without increases in positive end-expiratory pressure and peak airway pressure, thus minimizing the risk of alveolar rupture and worsening of lung injury.