Resp Care
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The incidence of congenital diaphragmatic hernia has been reported as 0.17-0.66 per 1,000 births. Despite advances in neonatal intensive care, congenital diaphragmatic hernia is associated with high mortality and morbidity. We report a neonate who was born with a left congenital diaphragmatic hernia and underwent surgical repair. ⋯ Presumably, the ventilator failed to respond to the patient's peak inspiratory flow demand, despite the clinician's setting the highest peak flow available. A time-cycled pressure-limited mode with adjustable peak flow rate was the only option that met the infant's flow requirement, and alleviated the respiratory distress. This clinical finding follows bench research that raises the concern that so called "cradle-to-grave" ventilators may not optimally support all neonates.
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Between 15% and 35% of mechanically ventilated patients fail an initial spontaneous breathing trial. For these patients, 40% of total time on mechanical ventilation is consumed by the weaning process (60% for patients with chronic obstructive pulmonary disease). Longer duration of mechanical ventilation is associated with higher risk of complications and probably with higher mortality. ⋯ Randomized controlled trials have indicated that, in selected patients with chronic obstructive pulmonary disease and acute-on-chronic respiratory failure, NIV can facilitate weaning, reduce the duration of invasive mechanical ventilation, decrease complications, and reduce mortality, compared to weaning on continued invasive ventilation. However, extubation failure resulting in re-intubation is associated with higher mortality, and this mortality risk increases with delay of re-intubation and may not be prevented by application of NIV. Patients extubated to NIV must have careful monitoring by skilled clinicians able to provide timely re-intubation if the patient shows signs of intolerance or worsening respiratory failure.
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In patients with acute respiratory distress syndrome (ARDS), inhaled vasodilator can result in important physiologic benefits (eg, improved hypoxemia, lower pulmonary arterial pressure, and improved right-ventricular function and cardiac output) without systemic hemodynamic effects. Inhaled nitric oxide (INO) and aerosolized prostacyclins are currently the most frequently used inhaled vasodilators. Inhaled prostacyclins are as effective physiologically as INO and cost less. ⋯ No outcome studies have been reported on the use of prostacyclin in patients with ARDS. There is no role for the routine use of inhaled vasodilators in patients with ARDS. Inhaled vasodilator as a rescue therapy for severe refractory hypoxemia in patients with ARDS may be reasonable, but is controversial.