Resp Care
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Randomized Controlled Trial Comparative Study
Comparison of optimal positive end-expiratory pressure and recruitment maneuvers during lung-protective mechanical ventilation in patients with acute lung injury/acute respiratory distress syndrome.
In patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), the use of alveolar-recruitment maneuvers to improve oxygenation is controversial. There is lack of standardization and lack of clinical studies to compare various recruitment maneuvers. Recruitment maneuvers are closely linked to the selection of positive end-expiratory pressure (PEEP), which is also a subject of debate. ⋯ Sighs superimposed on lung-protective mechanical ventilation with optimal PEEP improved oxygenation and static compliance in patients with early ALI/ARDS.
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New features of mechanical ventilators are frequently introduced, including new modes, monitoring techniques, and triggering techniques. But new rarely translates into any measureable improvement in outcome. We describe 4 new techniques and attempt to define what is a new invention versus what is innovative-a technique that significantly improves a measurable variable. We describe and review the literature on automated weaning, automated measurement of functional residual capacity, neural triggering, and novel displays of respiratory mechanics.
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Extracorporeal membrane oxygenation, a form of artificial circulatory support, continues to evolve beyond its well-established neonatal applications. It is often the most aggressive aspect of treatment algorithms in the management of severe respiratory and cardiac failure. While its use is relatively infrequent and executed in a small number of centers, it remains an important supportive measure while organ function is preserved and restored. Refinements in equipment and techniques continue to develop; patient-selection has changed, in adults and children, and cardiac applications have gained prominence.
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Postoperative pulmonary hypertension is a challenging and feared complication of many types of surgery, including lung and heart transplantation, pulmonary thromboendarterectomy, congenital-heart-disease repair, and others. The most severe manifestation is acute right heart syndrome, characterized by right heart failure and cardiovascular collapse-a daunting therapeutic challenge associated with a high mortality. Patients with postoperative pulmonary hypertension must be carefully evaluated to identify reversible contributing factors such as fluid and metabolic imbalance, hypoxemia, and right heart ischemia. ⋯ Basic principles of management include maintenance of systemic perfusion pressure, optimization of cardiac inotropy, use of lung-protective ventilator strategies, and attempting to reduce right-ventricular afterload using pulmonary vasodilators. Unfortunately, controlled trials upon which to base therapy are lacking, and most approaches are supported only by uncontrolled or anecdotal evidence. Better understanding of the pathophysiology of right heart failure and controlled trials testing therapeutic approaches are needed if we are to make progress in treating this heretofore highly mortal condition.