Current opinion in critical care
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The decision to extubate is a crucial moment for intubated patients. In most cases, the transition to spontaneous breathing is uneventful, but in some patients, it implies a more challenging decision. Both extubation delay and especially the need for reintubation are associated with poor outcomes. We aim to review the recent literature on weaning and to clarify the role of certain interventions intending to help in this process. ⋯ Current research is focusing on preventing extubation failure, especially in the most challenging cases. The use of weaning protocols - written or computerized - attempts to early identify patients who are able to breathe spontaneously and to hasten extubation, resulting in better outcomes. Nevertheless, individualized care is needed in the most vulnerable patients, trying to prompt weaning without exposing patients to unnecessary risks.
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Pulmonary arterial hypertension (PAH) is a complex disease with a high mortality. Management of this disease is underpinned by supportive and general therapies delivered by multidisciplinary teams in specialist centres. In recent years, a number of PAH-specific therapies have improved patient outcomes. This article will discuss the management of PAH in the context of relevant recently published studies in this area. ⋯ Outcomes in PAH have improved in recent years through a management approach characterized by general and supportive measures, and PAH-specific and surgical therapies in selected patients. Continued development of patient registries is vital to improve understanding and outcomes of this disease.
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Mechanical ventilation is one of the most important life support tools in the ICU, but it may also be harmful by causing ventilator-induced lung injury (VILI) and other deleterious effects. Advances in ventilator technology have allowed the introduction of numerous ventilator modes in an effort to improve gas exchange, reduce the risk of VILI, and finally improve outcome. In this review, we will summarize the studies evaluating some of the nonconventional ventilation techniques and discuss their possible use in clinical practice. ⋯ Apart from the physiological and clinical attractiveness demonstrated in animals and small human studies, most of the nonconventional ventilator modes must prove their clinical benefits in large prospective trials before being applied in daily clinical practice.
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Fluid management is one of the most important measures shown to impact acute respiratory distress syndrome (ARDS) outcomes. This review summarizes the current strategies aimed at evaluating and modulating lung fluid balance. ⋯ Dynamic monitoring of lung fluid balance needs to be implemented to guide fluid therapy in ARDS patients. A conservative fluid strategy seems safe and yields overall good clinical outcomes, but its impact on cognitive function needs to be evaluated in further studies. The role of colloids and other pharmacological agents deserves further investigation.