Current opinion in critical care
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Curr Opin Crit Care · Feb 2017
ReviewHow best to set the ventilator on extracorporeal membrane lung oxygenation.
Extracorporeal respiratory support in patients with acute respiratory distress syndrome is applied either as rescue maneuver for life-threatening hypoxemia or as a tool to reduce the harm of mechanical ventilation. Depending on the blood and gas flow, extracorporeal support may completely substitute the natural lung as a gas exchanger (high-flow venovenous bypass) or reduce the need for mechanical ventilation, enabling the removal of a fraction of the metabolically produced CO2. ⋯ Mechanical ventilation and extracorporeal support are marginally integrated. The best environment for lung healing - complete lung collapse or protective ventilation strategy or fully open and immobile lung (all three conditions feasible with extracorporeal support) - remains to be defined.
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Curr Opin Crit Care · Feb 2017
ReviewLimiting sedation for patients with acute respiratory distress syndrome - time to wake up.
Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. This review discusses the current evidence for sedation management in patients with ARDS. ⋯ Current evidence supports the use of protocol-based, light-sedation strategies in critically ill patients with ARDS. Further research into sedation management specifically in ARDS populations is needed.
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Curr Opin Crit Care · Feb 2017
ReviewRescue therapies for acute respiratory distress syndrome: what to try first?
Severe respiratory failure due to the acute respiratory distress syndrome (ARDS) might require rescue therapy measures beyond even extended standard care to ensure adequate oxygenation and survival. This review provides a summary and assessment of treatment options that can be beneficial when the standard approach fails. ⋯ A well timed, multimodal approach is required for patients with ARDS suffering from life-threatening hypoxemia. Understanding the limits of each type of rescue measure is of vital importance.
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Ventilator-induced lung injury (VILI) can occur despite use of tidal volume (VT) limited to 6 ml/kg of predicted body weight, especially in patients with a smaller aerated compartment (i.e. the baby lung) in which, indeed, tidal ventilation takes place. Because respiratory system static compliance (CRS) is mostly affected by the volume of the baby lung, the ratio VT/CRS (i.e. the driving pressure, ΔP) may potentially help tailoring interventions on VT setting. ⋯ Driving pressure is a bedside available parameter that may help identify patients prone to develop VILI and at increased risk of death. No study had prospectively evaluated whether interventions on ΔP may provide a relevant clinical benefit, but it appears physiologically sound to try titrating VT to minimize ΔP, especially when it is higher than 14 cmH2O and when it has minimal costs in terms of CO2 clearance.
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Curr Opin Crit Care · Feb 2017
ReviewContinued under-recognition of acute respiratory distress syndrome after the Berlin definition: what is the solution?
Timely recognition of acute respiratory distress syndrome (ARDS) may allow for more prompt management and less exacerbation of lung injury. However, the absence of a diagnostic test for ARDS means that the diagnosis of ARDS requires clinician recognition in what is usually a complicated and evolving illness. We review data concerning the extent of recognition of ARDS in the era of the Berlin definition of ARDS. ⋯ Significant numbers of patients with ARDS are still unrecognized by clinicians in the era of the Berlin definition of ARDS, with potentially important consequences for patient management and outcome.