Current opinion in critical care
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Curr Opin Crit Care · Feb 2020
ReviewPatient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing.
The potential risks of spontaneous effort and their prevention during mechanical ventilation is an important concept for clinicians and patients. The effort-dependent lung injury has been termed 'patient self-inflicted lung injury (P-SILI)' in 2017. As one of the potential strategies to render spontaneous effort less injurious in severe acute respiratory distress syndrome (ARDS), the role of positive end-expiratory pressure (PEEP) is now discussed. ⋯ To prevent P-SILI in ARDS, it seems feasible to facilitate 'safe' spontaneous breathing in patients using a higher PEEP strategy in severe ARDS.
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Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes quite challenging in the presence of spontaneous breathing activity. Aim of the present review is to describe how the different components of respiratory mechanics [resistance, static compliance, and intrinsic positive end-expiratory pressure (PEEP)] can be measured at the bedside during assisted modes of ventilation. ⋯ Assessment of respiratory mechanics in spontaneously breathing patients, with some limitations, is feasible and should be included in everyday clinical practice; however, more data are needed to understand the clinical relevance of the measures obtained during assisted ventilation.
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Curr Opin Crit Care · Feb 2020
ReviewExtracorporeal support to achieve lung-protective and diaphragm-protective ventilation.
Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring. ⋯ Technological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.
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Curr Opin Crit Care · Feb 2020
Lung protection in acute respiratory distress syndrome: what should we target?
Most clinical trials of lung-protective ventilation have tested one-size-fits-all strategies with mixed results. Data are lacking on how best to tailor mechanical ventilation to patient-specific risk of lung injury. ⋯ A precision medicine approach to lung-protective ventilation requires weighing four key factors in each patient: biological predisposition to biophysical lung injury, mechanical predisposition to biophysical injury accounting for spatial mechanical heterogeneity within the lung, anticipated benefits of escalating lung-protective interventions, and potential unintended adverse effects of mandatory cointerventions.
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Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). ⋯ Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.