Current opinion in critical care
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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
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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As incidence of acute lung injury (ALI) increases and case fatality decreases, long-term care of survivors is of public health importance. Previous studies demonstrate that these survivors are at risk for impairment in physical, cognitive and mental health. In this review, we will discuss recent studies that add to our knowledge of long-term outcomes after ALI and critical illness. ⋯ Physical, cognitive and mental health impairments after ALI are common, persistent and expensive. Future research is needed to improve prediction, prevention and treatment of these important sequelae.
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To describe the physiological meaning and the clinical application of the lung stress and strain concepts. ⋯ End-inspiratory stress and strain, as well as the lung inhomogeneity and the stress raisers, must be taken in account when setting mechanical ventilation.
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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.