Current opinion in critical care
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Curr Opin Crit Care · Feb 2006
ReviewUpdate of early respiratory failure in the lung transplant recipient.
Respiratory failure remains the most common complication in the perioperative period after lung transplantation. Consequently it is important to develop an approach to diagnosis and the treatment of respiratory failure in this population. This review highlights the advances made in the understanding and treatment of lung transplant patients in the early postoperative phase. Owing to its relative importance, advances in the understanding and treatment of ischaemia-reperfusion injury are highlighted. ⋯ Many advances have been made in the understanding of ischaemia-reperfusion injury. Owing to the acute and long-term implications of this complication, interventions that reduce the risk of developing ischaemia-reperfusion need to be evaluated in prospective clinical trials.
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Curr Opin Crit Care · Feb 2006
ReviewVentilation in the prone position in patients with acute lung injury/acute respiratory distress syndrome.
To contrast the beneficial effects of the prone position on the lungs and the lack of proven clinical benefits on patient outcome. ⋯ The prone position is not systematically used in hypoxemic patients. Patients who could benefit from prone position sessions are those with the most severe acute respiratory distress syndrome and those with dorsal lung infiltrates. Whether this can be translated into improvement in patient outcome has yet to be tested in clinical trials.
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Curr Opin Crit Care · Feb 2006
ReviewSurfactant therapy in adults with acute lung injury/acute respiratory distress syndrome.
Several phase II and phase III studies have been performed to investigate safety, efficacy and the improvement of survival due to exogenous surfactant instillation in patients with acute lung injury or acute respiratory distress syndrome. In this review we will discuss the most recent of these studies, paying particular attention to differences in the composition of the exogenous surfactant used, the diverse modes of delivery and dose of therapy and the influence of mechanical ventilation. ⋯ The changes in the surfactant system of patients with acute lung injury and acute respiratory distress syndrome form the rationale for the instillation of exogenous surfactant. There is enough evidence to use surfactant instillation for pediatric patients with acute lung injury. Due to the results of the randomized controlled trials performed so far, however, exogenous surfactant is not recommended for routine use in patients with acute lung injury or acute respiratory distress syndrome. In the future, other surfactants with different compositions may show beneficial effects.
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Curr Opin Crit Care · Feb 2006
ReviewLimitations of clinical trials in acute lung injury and acute respiratory distress syndrome.
To review the challenges and limitations of randomized clinical trials in acute respiratory distress syndrome, with special emphasis on those pertaining to ventilatory management. ⋯ Without tighter definitions of the condition under treatment, more specific targets for interventions to act upon, stratification that recognizes key interactive elements, and cointerventions based on better mechanistic understanding, randomized controlled trials of new drugs, ventilatory strategy, and other management approaches in acute respiratory distress syndrome are likely to remain a blunt instrument for investigation. As valuable as they are for calling important therapeutic principles to attention and for helping to suggest general guidelines for care, the limitations of randomized controlled trials for treating the individual with acute respiratory distress syndrome must be acknowledged.
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Curr Opin Crit Care · Feb 2006
ReviewThe impact of spontaneous breathing during mechanical ventilation.
In patients with acute respiratory distress syndrome, controlled mechanical ventilation is generally used in the initial phase to ensure adequate alveolar ventilation, arterial oxygenation, and to reduce work of breathing without causing further damage to the lungs. Although introduced as weaning techniques, partial ventilator support modes have become standard techniques for primary mechanical ventilator support. This review evaluates the physiological and clinical effects of persisting spontaneous breathing during ventilator support in patients with acute respiratory distress syndrome. ⋯ In view of the recently available data, it can be concluded that maintained spontaneous breathing during mechanical ventilation should not be suppressed even in patients with severe pulmonary functional disorders.