Seminars in respiratory and critical care medicine
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Traditionally, critically ill patients undergoing mechanical ventilation (MV) have received sedation. Over the last decade, randomized controlled trials have questioned continued use of deep sedation. Evidence shows that a nurse-driven sedation protocol reduces length of MV compared with standard strategy with sedation. ⋯ Moreover, delirium has gained increased focus in recent years with development of validated tools to detect both hyperactive and hypoactive forms of delirium. Using validated tools for detecting delirium is important in monitoring and detecting acute brain dysfunction in critically ill patients. Evidence from randomized trials also cites a beneficial effect of early mobilization with respect to length of MV and delirium.
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Semin Respir Crit Care Med · Aug 2014
Review Comparative StudyVentilator-Associated Lung Injury during Assisted Mechanical Ventilation.
Assisted mechanical ventilation (MV) may be a favorable alternative to controlled MV at the early phase of acute respiratory distress syndrome (ARDS), since it requires less sedation, no paralysis and is associated with less hemodynamic deterioration, better distal organ perfusion, and lung protection, thus reducing the risk of ventilator-associated lung injury (VALI). In the present review, we discuss VALI in relation to assisted MV strategies, such as volume assist-control ventilation, pressure assist-control ventilation, pressure support ventilation (PSV), airway pressure release ventilation (APRV), APRV with PSV, proportional assist ventilation (PAV), noisy ventilation, and neurally adjusted ventilatory assistance (NAVA). ⋯ Furthermore, during assisted MV, the following parameters should be monitored: inspiratory drive, transpulmonary pressure, and tidal volume (6 mL/kg). Further studies are required to determine the impact of novel modalities of assisted ventilation such as PAV, noisy pressure support, and NAVA on VALI.
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Ventilator-associated pneumonia (VAP) is an iatrogenic pulmonary infection that develops in tracheally intubated patients on mechanical ventilation for at least 48 hours. VAP is the nosocomial infection with the greatest impact on patient outcomes and health care costs. Endogenous colonization by aerobic gram-negative pathogens, that is, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus play a pivotal role in the pathogenesis of VAP. ⋯ In patients with clinical suspicion of VAP, respiratory samples should be promptly collected. The empiric treatment should be based on the local prevalence of pathogens, duration of hospital stay, and prior antimicrobial therapy. The antibiotics can be stopped or adjusted to more narrow-spectrum once cultures and susceptibilities are available.
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Semin Respir Crit Care Med · Aug 2014
ReviewExtracorporeal Support for Severe Acute Respiratory Failure.
Extracorporeal membrane oxygenation (ECMO) and extracorporeal CO(2) removal (ECCO(2)R) techniques have increasingly been applied in patients with severe acute lung injury refractory to conventional mechanical ventilatory support. The objectives of this article are to review current concepts of extracorporeal life support techniques (ECMO and ECCO(2)R systems) and provide the rationale for their application in patients with acute respiratory distress syndrome, chronic obstruction pulmonary disease, and as adjunctive therapy for bridging patients to lung transplantation.
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Semin Respir Crit Care Med · Aug 2014
Noninvasive Ventilation in Acute Hypercapnic Respiratory Failure.
Noninvasive mechanical ventilation (NIV) improves gas exchange and clinical outcome in various types of acute respiratory failure. Acute exacerbation of chronic obstructive pulmonary disease is a frequent cause of acute hypercapnic respiratory failure (AHRF). ⋯ Indications for the use of NIV have expanded over the past decade. In this article, we discuss the clinical indications and goals of NIV in the management of AHRF.