Seminars in respiratory and critical care medicine
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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.
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Airway access for mechanical ventilation (MV) can be provided either by orotracheal intubation (OTI) or tracheostomy tube. During episodes of acute respiratory failure, patients are commonly ventilated through an orotracheal tube that represents an easy and rapid initial placement of the airway device. ⋯ The aim of this review is to assess the frequency and performance of different surgical or percutaneous dilational tracheostomy and timing and safety procedures associated with the use of fiberoptic bronchoscopy and ultrasounds. Moreover, we analyzed the performance based on National European surveys to assess the current tracheostomy practice in ICUs.
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Sarcoidosis is a multifactorial and polygenic disorder. Recently, several novel predisposing genes have been identified by genome-wide association studies, and fast progress in molecular technologies such as systematic and large-scale resequencing will aid the discovery of further risk loci and variants. ⋯ This may lead to the development of new hypotheses on pathomechanisms, which associate sarcoidosis with other granulomatous disorders but also with diseases with significantly different phenotypes. In the near future system, biology approaches will help unravel the differing and common features of these disorders and allow the development of new therapeutic strategies and tools to predict the course and response to treatment of individual patients.