Current opinion in critical care
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Curr Opin Crit Care · Feb 2014
ReviewEpithelial and endothelial damage induced by mechanical ventilation modes.
The adult respiratory distress syndrome (ARDS) is a common cause of respiratory failure with substantial impact on public health. Patients with ARDS generally require mechanical ventilation, which risks further lung damage. Recent improvements in ARDS outcomes have been attributed to reductions in deforming stress associated with lung protective mechanical ventilation modes and settings. The following review details the mechanics of the lung parenchyma at different spatial scales and the response of its resident cells to deforming stress in order to provide the biologic underpinnings of lung protective care. ⋯ Heterogeneity of stiffness and intercellular and intracellular stress failure are fundamental components of ARDS and their development also depends on the ventilation mode.
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Fluid resuscitation in acute respiratory distress syndrome (ARDS) is not well documented. Clinical evidence comes from studies in critically ill patients, but these patients respond differently to fluids depending on the presence or absence of sepsis. ⋯ In order to evaluate the pros and cons of using fluids in ARDS patients, it is important to carefully analyze the latest trials. Recent studies have emphasized the importance of better understanding endothelial pathophysiology during fluid management in ARDS patients. Certainly, further studies analyzing fluid strategies in septic and nonseptic ARDS patients are needed.
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Esophageal pressure measurement well estimates pleural pressure. The interpretation of absolute values is often debated for various reasons, but the changes in pressure measured are considered very accurate provided that a number of precautions are taken. The information provided by these measurements is unique in nature and has an enormous potential to influence management. It allows to study the exact influence of the chest wall and to determine the real lung distending pressure. It is also the only way to quantify respiratory muscle activity and the work of breathing. ⋯ Application of esophageal pressure monitoring is limited by technical issues, the need for background physiological knowledge and the fact that very few studies have assessed a direct influence of this measurement on patients' outcome. The technique is underused in everyday practice.
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Curr Opin Crit Care · Feb 2014
Review Meta AnalysisVentilation with lower tidal volumes for critically ill patients without the acute respiratory distress syndrome: a systematic translational review and meta-analysis.
There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS as well. This manuscript systematically reviews recent preclinical studies of ventilation in animals with uninjured lungs, and clinical trials of ventilation in ICU patients without ARDS on the association between tidal volume size and pulmonary complications and outcome. ⋯ Ventilation with lower tidal volumes protects against pulmonary complications, but well-powered randomized controlled trials are urgently needed to determine whether this ventilation strategy truly benefits all ventilated ICU patients without ARDS.
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The article provides an overview of efforts to identify and validate biomarkers in acute respiratory distress syndrome (ARDS) and a discussion of the challenges confronting researchers in this area. ⋯ This article summarizes the current status of ARDS biomarker research and provides a framework for future investigation.