Seminars in respiratory and critical care medicine
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Because acute lung injury (ALI) may arise from diverse and heterogeneous clinical insults, monitoring strategies for patients with ALI are heterogeneous as well. This review divides the monitoring strategies for ALI into three distinct phases. The "at-risk phase" is the period in which patients are at risk for ALI, and interventions may be applied to minimize or eliminate this risk. ⋯ The primary goals are to optimize fluid resuscitation to prevent organ dysfunction, including ALI, and if ALI occurs to additional optimize fluid balance vis-à-vis the lung. By judicious application of invasive hemodynamic monitoring, particularly in its more modern iterations, clinicians can optimize the ebb and flow phases common to critically ill patients. This is vitally important given our current and growing understanding of the relationship between fluid balance and important clinical outcomes, multiple organ dysfunction syndrome, and mortality.
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The overarching goal of positive pressure mechanical ventilation is to provide adequate gas exchange support while not causing harm. Indeed, positive pressure mechanical ventilators are only support technologies, not therapeutic technologies. As such they cannot be expected to "cure" disease; they can only "buy time" for other therapies (including the patient's own defenses) to work. ⋯ In recent decades several novel or unconventional approaches to providing mechanical ventilatory support have been introduced. For these to be considered of value, however, it would seem reasonable that they address important clinical challenges and be shown to improve important clinical outcomes (e.g., mortality, duration of ventilation, sedation needs, complications). This article focuses on challenges facing clinicians in providing mechanical ventilatory support and assesses several novel approaches introduced over the last 2 decades in the context of these challenges.