Medicina intensiva
-
To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation. ⋯ In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated.
-
A reduction in both total lung volume and in lung parenchyma useful for gas exchange has been observed in ARDS patients. Applying an appropriate ventilatory pattern that includes PEEP can open up collapsed areas of the lung to aeration, thus ensuring a more homogeneous distribution of air in the lung. However, the heterogeneous patterns observed in patients with ARDS vary widely in their response to ventilation with PEEP. ⋯ Nevertheless, it is unclear whether RM are useful when patients are ventilated with high PEEP or when they have fibrosis, stiff chest wall, or hypovolemia, among other conditions. Likewise, decisions about RM must take into account not only their short- and long-term efficacy and reversibility, but also possible adverse effects derived from the high pressures reached during RM, including barotrauma, hemodynamic alterations, reduced systolic volume and aortic flow, and difficulties in venous return, as well as the possibility of bacterial translocation to the bloodstream or other organs. This article review the effects of RM as adjuvant treatment to mechanical ventilation in ARDS patients and discuss its efficacy and potential benefits as well as the different interactions that RM can have with the diverse conditions that can be associated to ARDS.
-
The spectrum of neuromuscular disease encountered in today's intensive care units (ICU) has evolved over the last few decades. However, in spite of many studies on neuromuscular disorders complicating critical illness as well as its epidemiology, etiology, treatment and prognosis, several key areas remain unclear. Two main groups are found among these neuromuscular abnormalities. ⋯ However, although we have better knowledge of its clinical, diagnosis, and prognosis features, its pathophysiological substrate has not been fully elucidated. Neuromuscular junction defects and specially myopathies, that frequently coexist with CIP, are the others main causes of acquired weakness in critically ill patients. Advances in understanding of these neuromuscular disorders could have an important impact in terms of developing effective preventive and therapeutic interventions that could help to improve the poor prognosis of these patients.
-
In recent years lung recruitment maneuvers (RM) have awakened an increasing interest due to their potential beneficial effects in lung protection so that they have been progressively introduced into clinical practice. Many clinical and experimental studies have described the physiological benefits obtained after lung re-expansion although these benefits are not uniform, partly because of the wide heterogeneity of the RMs applied and lack of criteria defining their goal. Therefore, to date it has been difficult to establish the role of recruitment in the ventilatory management of ARDS patients. ⋯ Lung recruitment must be applied in a protocolized and individualized way, establishing the pressure necessary to obtain the reasonably possible maximum lung re-expansion in each patient. Post RM PEEP adjustment is an essential aspect which, if ignored, renders RM useless and possibly without indication. Taking these essential aspects into account we are getting closer to, as the author believes, finally demonstrating the benefit of RM in lung protection and ARDS patients' outcome.