Seminars in respiratory and critical care medicine
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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
ReviewNoninvasive Ventilation in Withdrawal from Mechanical Ventilation.
Patients with chronic airflow obstruction and difficult or prolonged weaning are at increased risk for prolonged invasive mechanical ventilation (IMV). Several randomized controlled trials mainly conducted in patients who had pre-existing lung disease have shown that the use of noninvasive ventilation (NIV) to advance extubation in patients with difficult and prolonged weaning can result in reduced periods of endotracheal intubation, complication rates, and improved survival. ⋯ By contrast, NIV immediately after extubation is effective in avoiding respiratory failure after extubation and improving survival in patients at risk for this complication, particularly those with chronic respiratory disorders, cardiac comorbidity, and hypercapnic respiratory failure. Finally, both continuous positive airway pressure and NIV can improve clinical outcomes in patients with postoperative acute respiratory failure, particularly abdominal and thoracic surgery.
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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.
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Semin Respir Crit Care Med · Aug 2014
ReviewVentilatory Strategies in Severe Acute Respiratory Failure.
Lung-protective ventilator strategies are considered standard practice in the care of patients with the acute respiratory distress syndrome (ARDS). To minimize ventilator-induced lung injury, attention is directed at avoidance of alveolar overdistention and cyclical opening and closing. The lowest possible plateau pressure and tidal volume (V(T)) should be selected. ⋯ Volume and pressure limitation during mechanical ventilation can be described in terms of stress and strain. Fraction of inspired oxygen (Fio(2)) and PEEP are typically titrated to maintain arterial oxygen saturation (Spo(2)) of 88 to 95% (Pao(2) 55-80 mm Hg). There is currently no clear proven benefit for advanced modes.
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For many critically ill patients admitted to an intensive care unit, the insertion of an endotracheal tube and the initiation of mechanical ventilation (MV) can be lifesaving procedures. Subsequent patient care often requires intensivists to manage the complex interaction of multiple failing organ systems. The shift in the intensivists' focus toward the discontinuation of MV can thus occur late in the course of critical illness. ⋯ Many difficult aspects of pulmonary pathophysiology encroach on weaning management. Accordingly, weaning commands sophisticated, individualized care. Few other responsibilities of an intensivist require a more analytical effort and carry more promise for improving patient outcome than the application of physiologic principles in the weaning of patients.