Respiratory care clinics of North America
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Respir Care Clin N Am · Sep 2006
ReviewWhat is the role of airway pressure release ventilation in the management of acute lung injury?
The lack of published evidence supporting the use of APRV in the pediatric critical care patient population may diminish its effective application in respiratory failure. The effect of APRV on the number of ventilator days, ICU stay, and mortality still remains to be studied. Further application of APRV in the role of rest settings for ECMO especially in the pediatric cardiac patient population needs to be investigated. ⋯ Initially the comparison of APRV to HFOV needs to be the primary focus for a proactive approach for ALI. Once a comfort level is established with this modality, further scientific inquires will follow. In the meantime, its use is likely to remain controversial.
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Respir Care Clin N Am · Sep 2006
ReviewIs permissive hypoxemia a beneficial strategy for pediatric acute lung injury?
The adverse effects of high oxygen levels have been widely reported, and clinicians have struggled for many years to find the ideal balance between inspired oxygen levels and acceptable arterial oxygen saturation. However, when asked "what is an acceptable oxygen saturation," one is hard pressed to find a definitive answer. ⋯ It must be noted that this concept is predominantly based on physiology, as data in the medical literature are very limited. Permissive hypoxemia as an approach to acute lung injury remains controversial in the clinical setting.
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Respir Care Clin N Am · Sep 2006
ReviewThe role of noninvasive ventilation for acute respiratory failure.
The use of NIV has been shown to facilitate discontinuing ventilatory dependence as well as provide support for adult patients with chronic lung disease without the need for endotracheal intubation. In fact, NIV has recently described as a potential support strategy following extubation failure. Therefore, using NIV as a bridge to liberation from mechanical ventilation may decrease many of the complications associated with long-term use of invasive airway devices as well complications from reinsertion of an artificial airway. ⋯ Data from the adult population may be more readily adapted to older children; however, it remains difficult to determine the criteria for noninvasive ventilatory use in infants and young children. In fact, this lack of data makes the formulation of firm selection guidelines for infants and children essentially impossible. However, for a select groups of pediatric patients with acute respiratory failure for whom an appropriate noninvasive device with interface is available, a trial of NIV may be seem reasonable to avoid the known negative effects of intubation and invasive mechanical ventilation.
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Respir Care Clin N Am · Sep 2006
ReviewDo all mechanically ventilated pediatric patients require continuous capnography?
With most patients in modern ICUs requiring mechanical ventilation, any technology that may lead to more optimal ventilatory strategies would be invaluable in the management of critically ill patients. The focus of most ventilator strategies is protecting the lung from the deleterious effects of mechanical ventilation. Every effort is made to minimize the duration of mechanical ventilation while optimizing the potential for successful extubation. ⋯ Comprehensive evaluation of ventilatory management strategies and patient responses must be made by a collaborative effort of physicians, respiratory care practitioners, and nurses. An objective, consistent approach to the overall management is essential. Although still controversial, it is the authors' opinion that volumetric capnograph provides the data necessary to establish adequate gas delivery, optimal PEEP, and effective ventilation with the least amount of mechanical assistance, regardless of clinician or institutional preferences.
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Respir Care Clin N Am · Sep 2006
ReviewApplication of the acute respiratory distress syndrome network low-tidal volume strategy to pediatric acute lung injury.
In summary, most of the available data suggest that pediatric patients should be ventilated with low tidal volumes. The 6-mL/kg IBW tidal volume strategy as used in the ARDSNet studies is a reasonable target, having since been rigorously tested in several large, clinical trials (adult and pediatric). ⋯ With mortality rates in children from ALI nearing 8% to 22% and with no clear surrogate outcomes identified to date, the sample sizes needed to show a significant clinical effect would be prohibitively large. Nonetheless, future research should compare 6 mL/kg IBW to even smaller tidal volumes or to high frequency ventilation in an attempt to further reduce the mortality associated with ALI and ARDS in the pediatric population.