Respiratory care
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Noninvasive ventilation (NIV) for acute respiratory failure has gained much academic and clinical interest. Despite this, NIV is underutilized. The evidence strongly supports its use in patients presenting with an exacerbation of COPD and in patients with acute cardiogenic pulmonary edema. ⋯ Although a variety of interfaces are available, the oronasal mask is the best initial interface in terms of leak prevention and patient comfort. Some critical care ventilators have NIV modes that compensate well for leaks, but as a group the ventilators that are designed specifically for NIV have better leak compensation. NIV should be part of the armamentarium of all clinicians caring from patients with acute respiratory failure.
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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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Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass that is a mainstay of therapy in neonatal and pediatric patients with life threatening respiratory and/or cardiac failure. Historically, the use of ECMO in adults has been limited, but recent reports and technological advances have increased utilization and interest in this technology in adult patients with severe respiratory failure. As ECMO is considered in this critically ill population, patient selection, indications, contraindications, comorbidities, and pre-ECMO support are all important considerations. ⋯ Close monitoring is also necessary for complications, some of which are related to ECMO and others secondary to the patient's underlying degree of illness. Despite the risks, reports demonstrate survival > 70% in some circumstances for patients requiring ECMO for refractory respiratory failure. As the utilization of ECMO in adult patients with respiratory failure continues to expand, ongoing discussion and investigation are needed to determine whether ECMO should remain a "rescue" therapy or if earlier ECMO may be beneficial as a lung-protective strategy.
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The evolution of critical care and mechanical ventilation has been dramatic and rapid over the last 10 years and can be expected to continue at this pace into the future. As a result, the competencies of the respiratory therapist regarding mechanical ventilation in 2015 and beyond are expected to also markedly increase. ⋯ This requires an expanded education in a number of areas. To achieve these levels of competency, as recommended by the third "2015 and Beyond" conference, the entry level education of the respiratory therapist of the future must be at the baccalaureate level.
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The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. ⋯ This evidence base is growing, but the earlier guidelines are standing the test of time. Indeed, practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement, and further clinical studies, especially in the patient requiring PMV, are needed.