Current opinion in critical care
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Curr Opin Crit Care · Feb 2012
ReviewMeasures to prevent nosocomial infections during mechanical ventilation.
Endotracheal intubation and mechanical ventilation are lifesaving measures in critically ill patients. However, these interventions increase the risk of respiratory infections, particularly ventilator-associated pneumonia (VAP). VAP constitutes a serious burden for the healthcare system and worsens the patient's outcomes; thus, several preventive strategies have been implemented. This communication reviews the current knowledge on VAP pathogenesis and the latest preventive measures. ⋯ There is consistent evidence that strategies affecting the primary mechanisms of VAP pathogenesis efficiently reduce the occurrence of the disease. Preventive measures should be implemented grouped into bundles to improve overall efficacy.
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To describe the physiological meaning and the clinical application of the lung stress and strain concepts. ⋯ End-inspiratory stress and strain, as well as the lung inhomogeneity and the stress raisers, must be taken in account when setting mechanical ventilation.
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Electrical impedance tomography (EIT) is a useful noninvasive tool for monitoring ventilation finding its way into the clinical setting. The focus of this review is to discuss the balance between the potential for EIT as a clinical monitor accepting a level of uncertainty and the scientific demand for absolute perfection. ⋯ Already now EIT is a useful clinical monitor. Still more work is needed to develop and interpret indices which are simple enough to be used in the clinical setting to guide the clinician towards effective and safe ventilator management.
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Curr Opin Crit Care · Feb 2012
ReviewRole and potentials of low-flow CO(2) removal system in mechanical ventilation.
An analysis of the technological implementation of extracorporeal CO(2) removal (ECCO(2)R) techniques and of its clinical application. A new classification of ECCO(2)R, based on technological aspects, clinical properties and physiological performance, is proposed. ⋯ The future ventilatory management of patients with acute respiratory failure may include a minimally invasive extracorporeal carbon dioxide removal circuit associated with the least amount of ventilatory support (noninvasive in COPD and/or invasive in ARDS) to minimize sedation, prevent ventilator-induced acute lung injury and nosocomial infections. Randomized clinical trials in the pipeline will confirm this fascinating hypothesis.
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New developments in mechanical ventilation have focused on increasing the patient's control of the ventilator by implementing information on lung mechanics and respiratory drive. Effort-adapted modes of assisted breathing are presented and their potential advantages are discussed. ⋯ Within recent years, a major step forward in the evolution of assisted (effort-adapted) modes of mechanical ventilation was accomplished. There is growing evidence that supports the physiological concept of closed-loop effort-adapted assisted modes of mechanical ventilation. However, at present, the translation into a clear outcome benefit remains to be proven. In order to fill the knowledge gap that impedes the broader application, larger randomized controlled trials are urgently needed. However, with clearly proven drawbacks of conventional assisted modes such as pressure support ventilation, it is probably about time to leave these modes introduced decades ago behind.