Respiratory care
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Patient-ventilator synchrony and patient comfort are assumed to go hand in hand, yet few studies provide support for this common sense idea. In reality, synchrony between the patient and ventilator is complex and can be affected by the ventilator settings, type of ventilator, patient-ventilator interface, and sedation. ⋯ There is a clear association between asynchrony, ventilator-induced diaphragmatic dysfunction, and duration of mechanical ventilation. Whether these are cause and effect or simply associated remains to be determined.
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Relatively little attention has been directed toward damage inflicted upon the airway network that connects the alveoli, or toward the problems caused by invasive ventilation for patients with severe airflow obstruction. Mechanical ventilation with positive pressure can cause non-edematous barotrauma, inflict airway injury, and promote lung remodeling. ⋯ Awareness of such associations not only helps to avoid complications during and after the critical phase of obstructive illness, but also opens a window to improved patient comfort and safety. The purpose of this review is to survey the range of structural damages and functional impairments that occur in an "obstructive" context.
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Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. ⋯ A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the antimicrobial properties over time. Here, after reviewing the most noteworthy issues in VAP definition and pathophysiology, we will present the more interesting proposals for VAP prevention.
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Ventilator-induced lung injury (VILI) results from injury to the blood-gas barrier caused by mechanical ventilation. The determinants of VILI are more complex than originally thought, and include the nature, duration, and intensity of the exposure, as well the pattern of initial insult to the lung. ⋯ The purpose of this review is to provide a comprehensive assessment of the pathogenesis of VILI and its determinants. We also discuss the best preventive approach in patients with or at risk for ARDS and critically appraise the most recent evidence, expert opinion, and implementation of the acquired knowledge to the bedside.