Current opinion in critical care
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Curr Opin Crit Care · Feb 2010
ReviewVentilatory support for acute respiratory failure: new and ongoing pathophysiological, diagnostic and therapeutic developments.
Acute respiratory failure and its most severe form, the acute respiratory distress syndrome, are relatively common in the ICU setting and have a high morbidity and mortality. This article will discuss ongoing research in this area, with a focus on relatively novel approaches in terms of pathophysiology, diagnosis and therapeutic advancements. ⋯ It is increasingly evident that only integration of physiological, clinical and technological approaches will lead to improvement in the outcome of patients with acute respiratory failure.
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Acute kidney injury contributes to the development of acute lung injury and vice-versa. Volume overload that may occur during renal impairment increases pulmonary capillary hydrostatic pressure. However, experimental evidence clearly shows that lung damage occurs even in the absence of positive fluid balance. However, acute lung injury with its attendant hypoxemia, hypercapnia and mechanical ventilation worsens renal hemodynamics and function. ⋯ Fluid management optimization and prevention of inflammation and lung stretching are currently recommended for the treatment of acute lung and renal injury. Extracorporeal CO2 removal and renal replacement associated with extracorporeal membrane oxygenation might be interesting options for a future approach to pulmonary/renal syndrome.
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Curr Opin Crit Care · Feb 2010
ReviewClinical trials in ventilator treatment: current perspectives and future challenges.
Mortality/morbidity-based end points have been useful in evaluating treatments that modulate 'mediator variables' with a large effect size. Ventilation is usually a supportive measure, and hence is best seen as a 'moderator variable'. It can, therefore, have only a modest impact on disease-specific mortality. In this context, over reliance on final outcome-based end points (mortality, length of stay, etc.) risks the abandonment of several potentially useful developments. These concepts are important in considering how future developments should be evaluated. ⋯ It is crucial that a more dynamic approach, not based on final outcome alone, is considered in designing new clinical trials involving new ventilation strategies.
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In the last 2 years, several reports have dealt with recruitment/positive end-expiratory pressure (PEEP) selection. Most of them confirm previous results and few add new information. ⋯ Indiscriminate application of recruitment maneuver in unselected acute respiratory distress syndrome population does not provide benefits. However, in the most severe patients, recruitment maneuver has to be considered and higher PEEP applied. To individualize PEEP, the expiratory phase has to be considered, and the esophageal pressure measurement to compute the transpulmonary pressure should be progressively introduced in clinical practice.