Respiratory care
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Recruitment maneuvers in ARDS are used to improve oxygenation and lung mechanics by applying high airway pressures to reopen collapsed or obstructed peripheral airways and alveoli. In the early 1990s, recruitment maneuvers became a central feature of a variant form of lung-protective ventilation known as open-lung ventilation. This strategy is based on the belief that repetitive opening and closing of distal airspaces induces shear injury and therefore contributes both to ventilator-induced lung injury and ARDS-associated mortality. ⋯ We also review the radiologic, rheologic, and histopathologic evidence regarding the nature of lung injury and the phenomena of recruitment and de-recruitment as it informs our perceptions of recruitment potential in ARDS. Major lung-protective ventilation clinical trial data and other clinical data are also examined to assess the practical necessity of recruitment maneuvers in ARDS and whether a subset of cases might benefit from pursuing recruitment maneuver therapy. Finally, a less a radical approach to recruitment maneuvers is offered that might achieve the goals of recruitment maneuvers with less risk of harm.
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Home noninvasive ventilation (NIV) improves disease courses of patients with respiratory insufficiency due to neuromuscular diseases. Data about appropriate ventilator settings for pediatric patients are missing. ⋯ Similar NIV settings fit all age groups of pediatric subjects with neuromuscular disease. Thus, we propose an expiratory positive airway pressure of 4-5 cm H2O, an inspiratory pressure delta of 8-10 cm H2O, and an age-oriented backup rate as a starting point for NIV titration. Patients with advanced disease stages might require slightly higher inspiratory positive airway pressures and backup rates.
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It is unknown whether lung mechanics differ between patients with pediatric ARDS and at risk for ARDS. We aimed to examine the hypothesis that, compared to ARDS, subjects at risk of ARDS are characterized by higher end-expiratory lung volume (EELV) or respiratory system compliance (CRS) and lower distending pressure (stress) applied on the lung or parenchymal deformation (strain) during mechanical ventilation. ⋯ Longitudinally, CRS and EELV were lower and strain and stress were higher in subjects with ARDS compared to subjects at risk for ARDS. These parameters behaved differently over time at PEEP values of 4 or 10 cm H2O. At these PEEP levels, strain and stress remained within safe limits in both groups.
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High-flow nasal cannula (HFNC) is an option for respiratory support in patients with acute hypoxic respiratory failure. To improve patient outcomes, reduce ICU-associated costs, and ease ICU bed availability, a multi-phased, comprehensive strategy was implemented to make HFNC available outside the ICU under the supervision of pulmonology or trauma providers in cooperation with a dedicated respiratory therapy team. The purpose of this study was to describe the education and implementation process for initiating HFNC therapy outside the ICU and to convey key patient demographics and outcomes from the implementation period. ⋯ A comprehensive implementation process and a robust therapy protocol were integral to initiating and managing HFNC in all hospital locations. Study findings indicate that patients with acute hypoxic respiratory failure can safely receive HFNC therapy outside the ICU with appropriate patient selection and staff education.