Respiratory care clinics of North America
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Acute respiratory distress syndrome (ARDS) was formally described in 1971; however, physicians have been describing this syndrome and associating pulmonary edema with sepsis or toxic origins for over 100 years. Recently, an international conference accepted definitional criteria for ARDS that have become the accepted standard. ARDS is triggered by a large number of insults that often do not directly affect the lung. ARDS progresses pathologically through exudative, proliferative, and fibrotic phases.
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The high mortality associated with acute respiratory failure and further exacerbation of the lung injury by mechanical ventilation continues to pose a challenge in the management of critically ill patients. By providing total gas exchange and complete lung rest, extracorporeal membrane oxygenation (ECMO) has improved the survival rate of selected neonatal, pediatric, and adult patients. Arteriovenous carbon dioxide removal (AVCO2R) was developed as a less labor intensive, less costly, and less complex technique of extracorporeal gas exchange, allowing near total CO2 removal.
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There is enough evidence to support the short-term beneficial effects and safety of administering inhaled NO to ARDS patients. This effect may be potentiated when inhaled NO is administered in conjunction with other therapies. The full spectrum of effects of inhaled NO remains to be elucidated. Long-term benefit in terms of mortality and duration of mechanical ventilation has not been demonstrated; more randomized trials probing these effects are needed.
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A convincing and internally consistent body of literature now suggests that the traditional high tidal volume, normoxic, normacapnic ventilation paradigm may retard healing of the acutely injured lung. A growing number of practitioners are now shifting first priority from optimizing gas exchange, oxygen delivery, or respiratory system compliance to ensuring adequate lung protection. This article reviews the basis for concern about traditional ventilatory support in ARDS and develops an approach based on current evidence and newer options for management.
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Respir Care Clin N Am · Dec 1998
ReviewAcute respiratory distress syndrome. Patient position and motion strategies.
A review of the literature since 1974 indicates that, although there is no consensus as to the mechanism, positioning strategies in patients with ARDS improve PaO2 and may diminish lung parenchymal damage. The effect of these maneuvers on patient outcomes is uncertain. There is no uniform algorithm for the application of these techniques; however, there is sufficient evidence cited in the referenced articles to support the use and early application of the techniques to improve oxygenation.