Current opinion in critical care
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To describe the management principles that have not been verified or tested but nonetheless successfully guide the logic of everyday practice at the bedside. ⋯ The practitioner of intensive care often has no choice but to make difficult decisions and to select a course of treatment that remains unguided by specific, scenario-specific evidence from observational studies and clinical trials. Experience gathered over many prior encounters combined with solid physiologic understanding helps to develop guiding principles and unproven rules of management that serve well in confronting complex, ever changing problems of acute illness. Although some element of trial and error is unavoidable, careful monitoring, short loop feedback, and mid-course corrections render many logic-driven and experience-driven decisions relatively safe to implement and often effective in an uncertain, high-stakes environment.
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Curr Opin Crit Care · Feb 2012
ReviewExtracorporeal membrane oxygenation for respiratory failure in adults.
This article reviews case series and trials that evaluated extracorporeal membrane oxygenation (ECMO) for respiratory failure and describes patient and circuit management in the modern era of ECMO support. ⋯ The latest generation of ECMO systems is more biocompatible, better performing and longer lasting. Although recent studies suggested that veno-venous ECMO might improve the outcomes of patients with ARDS, indications for ECMO use remain uncertain. Future trials of ECMO for severe ARDS should strictly control for standard-of-care mechanical ventilation strategies in the control group and early transportation on ECMO for patients in the intervention arm.
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Curr Opin Crit Care · Feb 2012
ReviewRole and potentials of low-flow CO(2) removal system in mechanical ventilation.
An analysis of the technological implementation of extracorporeal CO(2) removal (ECCO(2)R) techniques and of its clinical application. A new classification of ECCO(2)R, based on technological aspects, clinical properties and physiological performance, is proposed. ⋯ The future ventilatory management of patients with acute respiratory failure may include a minimally invasive extracorporeal carbon dioxide removal circuit associated with the least amount of ventilatory support (noninvasive in COPD and/or invasive in ARDS) to minimize sedation, prevent ventilator-induced acute lung injury and nosocomial infections. Randomized clinical trials in the pipeline will confirm this fascinating hypothesis.
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Curr Opin Crit Care · Feb 2012
ReviewNoninvasive ventilation for the immunocompromised patient: always appropriate?
Over the last few decades, the survival rate in critically ill immunocompromised patients has substantially improved, mainly because of advances in oncohematological treatments and management of organ dysfunctions in the ICU. As a result, the number of patients admitted to the ICU has rapidly grown. Immunocompromised patients in whom acute respiratory failure (ARF) develops often require mechanical ventilatory support. In these patients, noninvasive ventilation (NIV) has the potential of avoiding endotracheal intubation and its complications. This review will discuss the recent findings on the role of NIV in immunocompromised patients with ARF. ⋯ Use of NIV may not be appropriate for all immunocompromised patients. However, current evidence supports the use of NIV as the first-line approach for managing mild/moderate ARF in selected patients with immunosuppression of various origin.
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Curr Opin Crit Care · Feb 2012
ReviewThe role of high-frequency oscillatory ventilation in the treatment of acute respiratory failure in adults.
High-frequency oscillatory ventilation (HFOV) is increasingly used in adults with the acute respiratory distress syndrome (ARDS), who remain hypoxemic during conventional mechanical ventilation. In this review, we will summarize the trials evaluating HFOV in adults with ARDS and discuss issues relevant to the clinician regarding the use of HFOV. ⋯ HFOV theoretically meets the goals of lung-protective ventilation. On the basis of the current evidence, HFOV is associated with improvements in oxygenation in severe, adult ARDS. However, whether HFOV influences mortality, length of ICU stay, ventilator-free days, quality-of-life factors and is cost-effective remains to be determined. Large, prospective, randomized controlled trials such as the ongoing OSCAR and OSCILLATE trials will help further define the role of HFOV in adult ARDS.