Current opinion in critical care
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Curr Opin Crit Care · Feb 2016
ReviewAcute respiratory distress syndrome: shifting the emphasis from treatment to prevention.
Although results from clinical trials have advanced the treatment of acute respiratory distress syndrome (ARDS), mortality remains high. More recently, focus has shifted from treatment of ARDS to early identification and prevention in at-risk populations. ⋯ With this change in paradigm, come additional challenges and consideration in study design that depends not only on the intervention but also whether the intervention aims for a primary, secondary, or tertiary prevention of ARDS that targets a patient population for universal, selective, or indicated prevention. These epidemiologic concepts of prevention in public health also apply to ARDS and are relevant to the study population to target, the timing of the intervention relative to critical illness, the study design and outcomes to measure in an ARDS prevention study. This shift in focus is reflected by the new National Heart Lung Blood Institute Prevention and Early Treatment of Acute Lung Injury network, and signifies an overall movement away from reacting to and supporting acute organ failure after it is established to early detection and prevention in acute critical illness wherever and whenever it may occur.
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Curr Opin Crit Care · Feb 2016
ReviewCurrent incidence and outcome of the acute respiratory distress syndrome.
This article discusses recently published articles reporting the incidence and outcome of patients with the acute respiratory distress syndrome (ARDS). This is a difficult task since there is a marked variability regarding the methodology of the few, large epidemiological, and observational studies on ARDS. ⋯ On the basis of current evidence, it seems that the incidence and overall hospital mortality of ARDS has not changed substantially in the last decade. Independent of the definition used for identification of ARDS patients, reported population-based incidence of ARDS is an order of magnitude lower in Europe than in the USA. Current hospital mortality of combined moderate and severe ARDS reported in observational studies is greater than 40%.
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Curr Opin Crit Care · Feb 2016
ReviewCurrent and future status of extracorporeal life support for respiratory failure in adults.
The purpose is to review the development and current application of extracorporeal life support [ECLS, extracorporeal membrane oxygenation (ECMO)] in acute severe respiratory failure. ⋯ ECMO is the next step in the algorithm for management of severe respiratory failure unresponsive to conventional care.
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The aim of this review is to analyze innovative data pertaining to the clinical use of mechanical ventilation for children. ⋯ Despite the improvement observed in the last decades in the treatment of pediatric acute respiratory failure and the diffusion of innovative modes of mechanical ventilation, there are no clear and consistent guidelines for the use of mechanical ventilation for children. In several areas data are still lacking, and in many others they are extrapolated from studies performed in adults; the direct evaluation of results obtained from studies specific to the pediatric population is therefore crucial.
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Curr Opin Crit Care · Feb 2016
ReviewThe promises and problems of transpulmonary pressure measurements in acute respiratory distress syndrome.
The optimal strategy for assessing and preventing ventilator-induced lung injury in the acute respiratory distress syndrome (ARDS) is controversial. Recent investigative efforts have focused on personalizing ventilator settings to individual respiratory mechanics. This review examines the strengths and weaknesses of using transpulmonary pressure measurements to guide ventilator management in ARDS. ⋯ The measurement of transpulmonary pressure relies upon esophageal manometry, which requires the acceptance of several assumptions and potential errors. Notably, this includes the ability of localized esophageal pressures to represent global pleural pressure. Recent investigations demonstrated improved oxygenation in ARDS patients when positive end-expiratory pressure was adjusted to target specific end-inspiratory or end-expiratory transpulmonary pressures. However, there are different methods for estimating transpulmonary pressure and different goals for positive end-expiratory pressure titration among recent studies. More research is needed to refine techniques for the estimation and utilization of transpulmonary pressure to guide ventilator settings in ARDS patients.