Seminars in respiratory and critical care medicine
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A strong demand for new obstructive sleep apnea (OSA) therapies exists and several are emerging. Hypoglossal nerve stimulation is designed to activate upper airway muscles. The initial study from Inspire (Maple Grove, MN) suggests that the device will work well in a very selective group of OSA patients. ⋯ OSA phenotyping is not a therapy, but a way to determine exactly what causes airway collapse in each patient, which can vary substantially. This may allow for individualization of apnea therapy. New methods to prevent supine sleep and surgically implantable devices to treat OSA are also evolving.
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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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Semin Respir Crit Care Med · Aug 2014
ReviewNoninvasive Ventilation for Patients with Hypoxemic Acute Respiratory Failure.
Noninvasive ventilation (NIV) has an established efficacy to improve gas exchange and reduce the work of breathing in patients with hypoxemic acute respiratory failure. The clinical efficacy in terms of meaningful outcome is less clear and depends very much on patient selection and assessment of the risks of the technique. The potential risks include an insufficient reduction of the oxygen consumption of the respiratory muscles in case of shock, an excessive increase in tidal volume in case of lung injury, and a risk of delayed or emergent intubation. ⋯ In all cases, there is both a time window and a severity window for NIV to work, after which delaying endotracheal intubation may worsen outcome. The preventive use of NIV seems promising in this setting but needs more research. An emerging interesting new option is the use of high flow humidified oxygen, which seems to be intermediate between oxygen alone and NIV.