Seminars in respiratory and critical care medicine
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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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Chronic obstructive pulmonary disease (COPD) is characterized by expiratory flow limitation (EFL) due to progressive airflow obstruction. The various mechanisms that cause EFL are central to understanding the physiopathology of COPD. At the end of expiration, dynamic inflation may occur due to incomplete emptying the lungs. ⋯ When invasive MV is used, settings should be adjusted in a way that minimizes hyperinflation, while providing reasonable gas exchange, respiratory muscle rest, and proper patient-ventilator interaction. Further, weaning from MV may be difficult in these patients, and factors amenable to pharmacological correction (such as increased bronchial resistance, tracheobronchial infections, and heart failure) are to be systematically searched and treated. In selected patients, early use of NIV may hasten the process of weaning from MV and improve outcomes.
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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.