Current opinion in critical care
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Mechanical ventilation is the main supportive therapy for patients with acute respiratory distress syndrome. As with any therapy, mechanical ventilation has side effects and may induce lung injury. This review will focus on stretch-dependent activation of alveolar epithelial and endothelial cells and polymorphonuclear leukocytes, and apoptosis/necrosis balance. ⋯ The proportion of patients receiving protective ventilatory strategies remains modest. If efforts to minimize the iatrogenic consequences of mechanical ventilation are to succeed, there must be a greater understanding of the signal transduction mechanisms and the development of potential pharmacologic targets to modulate the molecular and cellular effects of lung stretch.
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Curr Opin Crit Care · Feb 2005
ReviewMechanical ventilation in acute respiratory failure: recruitment and high positive end-expiratory pressure are necessary.
To review as best the critical care clinicians can recruit the acute respiratory distress syndrome (ARDS) lungs and keep the lungs opened, assuring homogeneous ventilation, and to present the experimental and clinical results of these mechanical ventilation strategies, along with possible improvements in patient outcome based on selected published medical literature from 1972 to 2004 (highlighting the period from June 2003 to June 2004 and recent results of the authors' group research). ⋯ Stepwise PEEP recruitment maneuvers can open collapsed ARDS lungs. Higher levels of PEEP are necessary to maintain the lungs open and assure homogenous ventilation in ARDS. In the near future, thoracic CT associated with high-performance monitoring of regional ventilation (electrical impedance tomography) may be used at the bedside to determine the optimal mechanical ventilation of ARDS patients.
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This review critically examines recent literature related to applications of noninvasive ventilation in the acute setting. ⋯ The recent literature has refined some of the current indications for noninvasive ventilation in the acute-care setting, including chronic pulmonary obstructive disease and cardiogenic pulmonary edema. Guidelines for use are now being developed, and outcomes seem to be improving, partly as a consequence of greater caregiver experience and possibly related to technologic advances.
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Curr Opin Crit Care · Feb 2005
ReviewPulmonary and extrapulmonary acute respiratory distress syndrome: are they different?
Acute respiratory distress syndrome has been considered a morphologic and functional expression of lung injury caused by a variety of insults. Two distinct forms of acute respiratory distress syndrome/acute lung injury are described, because there are differences between pulmonary acute respiratory distress syndrome (direct effects on lung cells) and extrapulmonary acute respiratory distress syndrome (reflecting lung involvement in a more distant systemic inflammatory response). This article will focus on the differences in lung histology and morphology, respiratory mechanics, and response to ventilatory strategies and pharmacologic therapies in pulmonary and extrapulmonary acute respiratory distress syndrome. ⋯ The understanding of acute respiratory distress syndrome needs to take into account its origin. If each pathogenetic mechanism were to be considered, clinical management would be more precise, and probably the outcome could include real amelioration.